Transcrição completa de [Physio Explained] Clinical pearls for assessing hip dysplasia with Andrew Wallis

--> 00:05:05.673 So what we see is a situation where if someone has an anterior insufficiency, they will often have anterior pain. 00:05:05.713 --> 00:05:08.216 If they have more lateral undercoverage, it'll be lateral. 00:05:08.297 --> 00:05:14.266 And those that are one in six of them that have posterior insufficiency will see the pain more posteriorly. 00:05:14.689 --> 00:05:19.877 So I think that that's something to be really recognizing and something that's really, really important. 00:05:20.319 --> 00:05:24.144 Then it comes down to what do these people do that's going to bring it on? 00:05:24.324 --> 00:05:29.091 So I think most of the time they present most with an insidious onset of pain. 00:05:29.512 --> 00:05:30.694 I don't think it's normally sharp. 00:05:30.754 --> 00:05:31.935 It's more a dull ache. 00:05:32.396 --> 00:05:35.461 As we said, the symptoms are primarily directionally dependent. 00:05:35.841 --> 00:05:40.807 And I think most people will volunteer symptoms that are flexion-based. 00:05:41.187 --> 00:05:47.915 So walking upstairs, walking on an incline, gym-based activities that require you to squat or lunge or whatever. 00:05:48.355 --> 00:05:56.245 But I think it's really, really important that the treating clinician is aware that it is likely more an extension-based cause. 00:05:56.345 --> 00:06:02.672 So what I say to people then is, we need to push the envelope and ask about those symptoms because they're often not volunteered. 00:06:02.771 --> 00:06:05.660 So when you push it, People say, yeah, it is. 00:06:05.759 --> 00:06:07.923 It's when I stand for a prolonged period. 00:06:08.343 --> 00:06:09.785 It's when I lunge. 00:06:09.964 --> 00:06:10.887 Oh, so on the front leg. 00:06:10.947 --> 00:06:11.487 No, no, no, no. 00:06:11.648 --> 00:06:14.250 On the trail leg, like the leg that's being stretched. 00:06:14.791 --> 00:06:17.776 When I walk or I run, it comes on. 00:06:18.196 --> 00:06:20.819 So again, we have to ask the question, was it on the front or the back leg? 00:06:20.839 --> 00:06:22.901 Because most of the time it is on the trail leg. 00:06:23.403 --> 00:06:31.713 And so we see people who go to parties and potentially wear, say, high heels and stand for a prolonged period and fall into a sway back posture. 00:06:32.002 --> 00:06:38.370 And they tend to get those anterior symptoms because I think the hip is going into an extended position. 00:06:38.410 --> 00:06:41.033 We know we've only got sort of 10 degrees of hip extension. 00:06:41.093 --> 00:06:50.863 And I think a lot of them use up that isolated hip extension when they stand in sway and they're pushing on the front of the capsule, the synovium, the labrum, whatever it might be. 00:06:50.903 --> 00:06:58.973 And likewise, when they're walking or running, they tend to take a long stride, but it tends to be on that trail leg that they're getting the symptoms. 00:06:59.425 --> 00:07:03.732 And then I think other things they potentially present with is they'll describe mechanical symptoms. 00:07:04.293 --> 00:07:06.235 We're just not exactly sure what they are. 00:07:06.254 --> 00:07:10.180 So I'm talking here about catching, clicking, popping, locking, that sort of thing. 00:07:10.261 --> 00:07:20.274 But as we know, with any noise, it can be intra-articular, like it could be truly a labral tear or ligamentaries or something like that, or a loose body intra-articular. 00:07:20.314 --> 00:07:35.798 But probably in these typical patients, I think it is more likely that what we're seeing is that The tendons, recfam or psoas are flicking over the head of the femur or over the iliopectinal eminence as we go towards extension and particularly if it's brought on with some rotation. 00:07:36.560 --> 00:07:39.367 And then I think they often describe a feeling of instability. 00:07:39.387 --> 00:07:42.473 And I think that's through weakness more than anything. 00:07:42.733 --> 00:07:44.639 I don't think it is an instability issue. 00:07:44.678 --> 00:07:46.002 I think they get pain inhibition. 00:07:50.625 --> 00:08:15.218 This podcast is sponsored by Cliniko. 00:08:21.889 --> 00:08:34.024 It really does highlight that relevance and the importance of the follow-on questions and asking those specific questions because those are often where the hidden gems are. 00:08:34.125 --> 00:08:39.631 So it sounds like you will specifically ask about stairs, running, those sorts of things. 00:08:39.692 --> 00:08:43.475 Are there any other questions you typically find reveals a lot? 00:08:43.515 --> 00:08:51.306 No, other than asking some questions regarding a subject about what their rehab has been in the past. 00:08:51.586 --> 00:09:00.394 because I'm sure we'll talk about this when we get to rehab, but there's a few things that instability really doesn't like as far as rehab goes. 00:09:00.794 --> 00:09:02.395 One of them is extension. 00:09:03.116 --> 00:09:15.648 So being forced into extension during, say, a hip flexor stretch when someone's told, oh, you know, you're really tight in there and they haven't recognized that that tightness is hypertonicity and they try and force through it. 00:09:15.668 --> 00:09:21.354 So I think this is actually a really good question by you because I think it highlights the things maybe we shouldn't do. 00:09:21.826 --> 00:09:23.427 So I wouldn't force extension. 00:09:23.948 --> 00:09:26.873 I'd use myofascial techniques and things like that to reduce tone. 00:09:27.173 --> 00:09:31.480 As long as we are re-strengthening that person and retraining movement patterns, that's okay. 00:09:32.020 --> 00:09:33.884 The other thing they really don't like is clams. 00:09:34.124 --> 00:09:35.625 I think there's two reasons for that. 00:09:35.826 --> 00:09:41.875 One is we know once you bend past 45 degrees that the abductors become internal rotators. 00:09:41.894 --> 00:09:49.145 So I think often what happens is you get a reduction in the external rotator capacity of the hip.

00:09:49.666 --> 00:09:53.451 And because they become abductors, the abductors become internal rotators. 00:09:53.551 --> 00:09:55.573 And what takes over is iliacus. 00:09:56.054 --> 00:09:57.817 And iliacus is a strong external rotator. 00:09:57.837 --> 00:09:59.440 It's the only one that can work in that position. 00:09:59.480 --> 00:10:03.865 And it frictions across the front of whatever's already irritated, the labrum or the rim. 00:10:04.547 --> 00:10:06.389 And most people you speak to won't like that. 00:10:06.429 --> 00:10:12.238 The other thing is that clams effectively take you into a faber position, flexion, abduction, external rotation. 00:10:12.546 --> 00:10:25.042 And we know that anyone who has femoral anteversion can't do that because they get a bony block at the back, a contact between the posterior acetabulum and the posterior aspect of the neck of the femur, and then levers out the front. 00:10:25.522 --> 00:10:30.788 So we're a little bit cautious about faber maneuvers, clams, that sort of thing. 00:10:31.048 --> 00:10:41.402 And I think that's why stretching into that alleged short adductor position of splaying your legs like a butterfly, frog leg positions, they don't like that either. 00:10:41.793 --> 00:10:45.658 Which I suppose will lean right into the objective assessment. 00:10:46.240 --> 00:10:50.525 Flowing on from your subjective, what do you typically see in your physical assessment? 00:10:51.226 --> 00:10:54.952 Oh, look, I'm a big fan of identifying things as soon as people come in. 00:10:55.013 --> 00:10:57.635 And I think often their gait is a bit of a giveaway. 00:10:57.655 --> 00:11:06.083 I think they either have a Trendelenburg gait or don't forget the old Gluteus Medius gait so that Trendelenburg is when we drop down. 00:11:06.144 --> 00:11:12.070 Aglutius medius is when we sort of hitch up to prevent dropping down because they know they're a bit weak and they're going to drop down. 00:11:12.509 --> 00:11:13.792 I'll talk about that a little bit in a minute. 00:11:14.452 --> 00:11:20.798 I don't think as therapists or clinicians, we're particularly good at examining extension. 00:11:21.179 --> 00:11:25.403 And unfortunately, we need to be pretty good at it to diagnose dysplasia. 00:11:25.443 --> 00:11:28.368 And we'll get there, but it's the new frontier. 00:11:28.488 --> 00:11:32.272 So I think identifying a swayback posture is really key. 00:11:32.312 --> 00:11:41.118 And look, you can go online and see that, but The definition of a swayed back really is that the pelvis sits in front of your shoulder and your foot line or your ankle line. 00:11:41.599 --> 00:11:43.763 And so effectively, they're standing in extension. 00:11:43.783 --> 00:11:47.428 But I think the thing that often goes with that is posterior pelvic tilt. 00:11:47.830 --> 00:11:49.712 And we'll talk about correction of that later. 00:11:49.732 --> 00:11:54.562 But basically, I think about that someone resting at the very end of range. 00:11:54.601 --> 00:11:56.765 You imagine if you took your shoulder into position. 00:11:57.057 --> 00:12:02.706 flexion, abduction, external rotation, and held it there for a prolonged period, the front of your shoulder would be screaming. 00:12:02.725 --> 00:12:04.727 And I think that's what happens a little bit in this. 00:12:04.847 --> 00:12:08.212 So just identifying their standing posture is absolutely critical. 00:12:08.874 --> 00:12:13.119 I don't think we're particularly good at identifying head of femur translation. 00:12:13.440 --> 00:12:25.091 And so two things we tend to do are ask them when you're looking at their lumbar spine, ask them to bend into extension and palpate the back of the great trochanter, which is about as close as we can get to feeling the head of the femur. 00:12:25.131 --> 00:12:31.259 I'm not foolish enough to believe we can feel that, but I think you can note someone translating forward with that. 00:12:31.480 --> 00:12:39.792 So we identify that when someone bends into lumbar extension, they should have symmetrical and minimal anterior translation of the head of the femur. 00:12:39.851 --> 00:12:43.437 We shouldn't have asymmetrical movement and we certainly shouldn't have excessive movement. 00:12:43.817 --> 00:12:53.157 And then To follow that up, we then ask someone to stand on one leg with our thumbs still behind the agrotricantra and identify whether they translate significantly forward there. 00:12:53.197 --> 00:12:56.000 And I think that's another key element of the assessment. 00:12:56.341 --> 00:12:58.744 And then all the stuff I think that everyone knows. 00:12:58.783 --> 00:13:07.354 So making sure that we look at single leg stance and identify whether they have a loss of lateral pelvic stability or femoral rotational control. 00:13:07.394 --> 00:13:09.336 And then doing the isolated testing. 00:13:09.356 --> 00:13:13.341 We use a Hogan handheld dynamometer to look at abduction. 00:13:13.730 --> 00:13:24.166 adduction, IR and ER, and we pretty much follow Christian Thorberg's work of sitting or lying in supine and doing that in a neutral position and then turning into prone and doing the testing. 00:13:24.746 --> 00:13:39.609 Part of the reason we don't test in 90 degrees, so in seated for IR, ER is what we discussed before, that your function around the hip, and Newman's work showed this, but your abductors become internal rotators and your external rotators become abductors. 00:13:39.629 --> 00:13:42.693 So I think we've got to be a bit careful about what position we test in. 00:13:43.042 --> 00:13:46.044 And we've got some figures that we use around that. 00:13:46.105 --> 00:13:58.359 Obviously, it depends what you're using, but if you're using newtons, we'd like people to have coronal plane strength of abductors and adductors around 150 and 135 for the rotators, internal and external rotators. 00:13:58.379 --> 00:14:06.267 And that obviously is variable depending on your bias to whatever your sex

is or your size and all those sort of things that we account for. 00:14:06.606 --> 00:14:14.764 And just to point on that, I think people can be incredibly strong when they are isolated tested, but not so good when they do dynamic things. 00:14:15.144 --> 00:14:20.030 So you look at these people, they blow it up, the machine, but their single leg control is terrible or vice versa. 00:14:20.291 --> 00:14:25.118 We see people with amazing control and we see them when they do an isolated test, they're not so good. 00:14:25.158 --> 00:14:26.519 So I think we've got to do both. 00:14:27.000 --> 00:14:31.807 Other special tests for dysplasia, I think the positive apprehension or relocation test. 00:14:31.826 --> 00:14:34.870 So we tend to do it in a modified Thomas test position. 00:14:34.931 --> 00:14:37.955 I think it's a much safer position to do it in. 00:14:38.274 --> 00:14:43.642 I think you can see the patient's face as you Take them into extension and you can relocate it with your hand. 00:14:43.682 --> 00:14:46.184 It's very similar to the shoulder apprehension test. 00:14:46.825 --> 00:15:01.722 There are some very wise people who always said to me, do your apprehension and relocation test in a standing position where a patient could get away from that fear and move the body to get away from an apprehensive position as opposed to lying in supine. 00:15:01.743 --> 00:15:02.783 I think the same thing here. 00:15:02.844 --> 00:15:04.385 I feel like a patient could get out of it. 00:15:04.706 --> 00:15:08.509 Because there are some people who teach you to do it in prone and lift into extension. 00:15:08.570 --> 00:15:14.437 I think that's a, if you see a lot of dysplastic patients, it's a very fearful position for people because they just have nowhere to go. 00:15:14.456 --> 00:15:25.548 I say a positive in inverted commas, impingement test, end inverted commas, because they will be sore into flexion, adduction, internal rotation. 00:15:26.109 --> 00:15:28.172 But as we know, that's not an impingement test. 00:15:28.251 --> 00:15:30.214 It was originally designed as a labral test. 00:15:30.754 --> 00:15:38.528 And I do think it identifies some labral irritation, but the likely scenario is that these people have gone into hip extension. 00:15:38.567 --> 00:15:44.317 They have sheared the head of the femur forward and irritated the labrum from an inside-out lesion. 00:15:44.759 --> 00:15:46.081 The labrum is now irritated. 00:15:46.100 --> 00:15:51.289 And of course, when you take it into a flexion adduction internal rotation position, it is sore to do that. 00:15:51.471 --> 00:15:53.313 It doesn't mean they've got impingement. 00:15:53.761 --> 00:15:58.549 And then probably the final thing is just to be a bit more aware, again, the new frontier. 00:15:58.929 --> 00:16:03.638 I think we're a lot more aware now of connective tissue disorders and the accompanying of that. 00:16:03.677 --> 00:16:09.147 Obviously, we're talking about dysplasia and that's an architectural, morphological, bony type lesion. 00:16:09.167 --> 00:16:09.667 We get that. 00:16:10.168 --> 00:16:13.673 But I think we are becoming a bit more aware of the whole package. 00:16:13.793 --> 00:16:18.701 So maybe doing the tests that we all know, the Baten's test, nine score, which is objective. 00:16:19.073 --> 00:16:23.941 It has been suggested that we should probably do the Hockham-Graham test as well because that's subjective. 00:16:24.181 --> 00:16:25.503 And I think that's a really good point. 00:16:25.543 --> 00:16:32.312 And that's a retrospective test that potentially, let's look at the scenario here where we have an 18-year-old female come in. 00:16:32.793 --> 00:16:35.657 She's going to present with hypermobility on the Baten score. 00:16:35.977 --> 00:16:44.188 But a 53-year-old female who is potentially a bit stiffer because we recognize connective tissue stiffness occurs as we get older. 00:16:44.802 --> 00:16:48.426 We might miss something there because we look at her and she passes the bait and test. 00:16:48.466 --> 00:16:51.469 She probably has one or two out of those nine that are positive. 00:16:51.969 --> 00:16:55.412 But if you ask her retrospectively, did you have any party tricks? 00:16:55.471 --> 00:17:01.739 She says, yeah, I used to be able to hyperextend my elbows and my knees and I used to bump hip out to the side and make that clunking. 00:17:01.798 --> 00:17:07.384 And so that might be something that we ask retrospectively that gives us a bit more of a complete picture. 00:17:07.744 --> 00:17:11.728 Because as we know, none of these tests should be taken in isolation. 00:17:11.989 --> 00:17:12.449 They're all... 00:17:13.473 --> 00:17:16.599 Exactly 00:17:16.660 --> 00:17:16.840 right. 00:17:16.901 --> 00:17:19.144 And they flow in from your subjective. 00:17:19.605 --> 00:17:21.951 I think that's an excellent summary. 00:17:21.990 --> 00:17:32.973 Can you, and I know you and I have discussed this before in the way of apprehension tests, you've obviously got patients that are apprehensive and they're in pain. 00:17:33.377 --> 00:17:49.818 There's a whole battery of tests often, and it sounds like you typically more lean towards, it's more a clearance process rather than going through a whole range of tests to confirm multiple times that there is apprehension or that there might be instability. 00:17:50.539 --> 00:17:53.163 Yeah, we teach the courses and we teach all of those tests. 00:17:53.242 --> 00:17:58.470 And there's three tests, as you know, the ab here and that prone rotation test, all those sort of things. 00:17:58.549 --> 00:18:11.729 But I keep coming back to what I use clinically and that is the apprehension test in a modified Thomas test position because I think it gives you the answer as many clinicians will say that see a lot of one thing. 00:18:11.749 --> 00:18:14.432 Once you've got the answer, you don't need to keep looking for it. 00:18:15.173 --> 00:18:15.394 And 00:18:15.815 --> 00:18:20.141 hopefully you've got a slightly happier hip not having done a multitude of tests. 00:18:20.705 --> 00:18:22.711 Yeah, we've all made that mistake though, haven't we? 00:18:22.750 --> 00:18:30.771 First year out of uni or we go and do a course and Monday morning the poor first patient gets about 2,000 tests and limps out of there. 00:18:30.892 --> 00:18:31.614 Yeah, yeah. 00:18:31.746 --> 00:18:34.369 I'm not the only one who's done that, I'm 00:18:34.390 --> 00:18:34.470 sure. 00:18:34.490 --> 00:18:35.751 Double check and triple check. 00:18:36.353 --> 00:18:36.554 Yeah. 00:18:37.034 --> 00:18:39.719 Well, Andrew, that was absolutely fantastic. 00:18:39.778 --> 00:18:48.772 There are so many clinical gems in all of that and I'm looking forward to talking about the treatment side of things as well very soon. 00:18:49.233 --> 00:18:50.556 So thank you so much for your time. 00:18:50.997 --> 00:18:51.557 Pleasure, Sarah. 00:18:51.577 --> 00:18:56.925 Thank you.