All right, I'd like to thank you all for the opportunity to present this information and be part of this faculty. It's certainly an honor to be included. I don't have any disclosures or conflicts of interest. So what I'll be talking about is rehabilitation strategies and potential indications for surgery. So just to kind of put a summary on it, as physical therapists, we use a classification-based treatment. We try to identify impairments, which would include range of motion and strength deficits. And then we'd also try to correct any movement dysfunctions. So the first part of any good exam begins with a good history. And we want to make sure that the patients that we're seeing particularly have musculoskeletal problems. So with posterior hip pain, there can be some overlap. And we want to make sure that from a physical therapy standpoint, it is something that we can treat. So here's just a brief list of potential causes, really not an inclusive list, but something that we consider. And then as far as specific symptom presentations. So these would be the patient had this particular presentation would make us be concerned that maybe this wasn't a musculoskeletal problem. There are key questions that we make sure to include on a health history. Some of these can be uncomfortable to ask. So it's often done, you know, by, you know, kind of a questionnaire type format. But certainly these are things we want to make sure that we at least address and make sure that there aren't any problems that would give us cause for concern as not to move on with treatment. From a physical therapy standpoint, these would be some musculoskeletal causes of hip pain that we would look that we could potentially intervene with. Related to posterior hip pain, we did publish a nice review on the evaluation and management that was published in 2018 in the Journal of the American Academy of Orthopedic Surgeons. So this runs through the various pathologies, how they would present, and some specific evaluation techniques, some of which I'll review here, but this is a nice review. As far as a classification of physical therapists, try to break things down into your lumbosacral, extra articular, intraarticular. And then if they're intraarticular causes, we would specifically look at for impingement, hypermobility, hypomobility, or something of a traumatic onset. There are quite a few tests that we would perform throughout the examination that are listed here. I don't want to go through all of them, but this would be kind of an overview of our thought process of our examination. If we're thinking about a differential diagnosis, this would be our differential dose diagnosed for groin pain. There's also lateral hip pain, but obviously this talk has to do with posterior hip pain. So when someone presents with posterior hip pain, this would kind of be our differential diagnosis list. Also with posterior hip pain, I think it's important to remember the relationship between the hip and spine and specifically looking for, you know, is it a spine-hip or hip-spine problem? Spine-hip problems can present with muscular weakness of the gluteal and abdominal muscles and impact dynamic movement. Degenerative spine conditions can relate to lumbosacral hypermobility and present with decreased range of motion. When we get to hip-spine problems, really look primarily for hip joint hypermobility and specifically loss of hip extension that would most commonly cause by an iliopsoas contracture, but could also be tight anterior capsule. Also some things to consider in those that present with loss of hip extension would be femoral anteversion or acetabular anteversion. Another condition would be ischiofemoral impingement. So all those could be, you know, primary hip problems that could lead to spine conditions. Anything that limits terminal hip extension can cause an increase in pelvic rotation, increase lordosis, and cause facet overloading. So again, in those with, you know, hip and spine combined problems, you know, we would look to see if we can improve particular hip extension. When we move through identifying it as a hip versus lumbosacral problem, there are a couple of tests I want to highlight here. I want to be just looking for pelvic landmark symmetry, so make sure there's no leg length discrepancies or any pelvic rotational problems. We'll go through lumbar range of motion, including overpressure as appropriate to identify if we can reproduce the patient's symptoms. And as we're moving through this exam, looking to collect impairments that we might be able to treat. The standing hip flexion test and the long sitting test would help identify sacroiliac problems that might respond to a joint mobilization technique. So as we move through our classification system after we identify is there a hip and or lumbosacral spine problem, next would be to identify is it intra or extra articular. So when we look at intraarticular pathologies, we're looking for, you know, particularly loss of hip internal rotation. That would be the biggest indication for me, followed by a loss of hip flexion. So those would kind of identify I'm dealing with an intraarticular hip problem versus extraarticular hip problem. As you move to the extraarticular part of our exam, we would try to identify the specific structure. And if we're thinking of muscle tendon problems, you know, the pain should be reproduced when we with palpation with flexibility tests and resistive tests. So if I am dealing with a musculotendinous issue, I should be able to reproduce the pain. As we move into the specific posterior hip pain diagnosis, sciatic nerve entrapment, pudendal nerve entrapment, hamstring strange, and ischiofemoral impingement, this is our summary of special tests that I would go through to rule in or out each of these conditions. If we look at, you know, exactly where the nerve can be impinged when we're talking about posterior nerve entrapments, you can have the sciatic nerve entrapment at the level of external rotators at the level of the ischium, and then pudendal nerve entrapment can occur at Alcox canal. To identify the source of nerve entrapment, look for where the source of pain is primarily. So medial to the issue would be pudendal. At the level of the ischium would be, or lateral to the ischium would be sciatic nerve entrapment, you know, usually by the hamstrings, and then entrapment at the level of the external rotators or piriformis muscles would cause pain in that location. The seated palpation has been described by Dr. Hale-Martin as a test that you can use to specifically identify the source of pain. For looking at deep glial nerve entrapment, you have the active piriformis, you have the seated piriformis stretch test. If we're looking at hamstring strains, we would use the active 30 or 90, and then the long heel strike test. For ischiofemoral impingement, there is the IFI test. We also have the long stride test. So I don't want to go into a whole lot of details about these. These have been published and described in the literature with their appropriate diagnostic accuracy. I think for physical therapists, one thing we want to make sure we do is look for movement system disorders. So we would include a functional assessment, which would include the single leg squat, single leg stance, medial hop test. And these do have literature to support their usefulness that has been published. To me, the most valuable test I would use would be the single leg squat as it's able to be done by most people and can identify deviations or movement dysfunctions that could occur at the hip, pelvis, and trunk. So after we identify the classification-based treatment, we try to put together a problem list, and this will obviously guide our intervention. So, you know, try to classify the person, then put together the problem list, and try to identify the movement system dysfunction. So as we go into specific treatments over these conditions, if there is a lumbosacral condition identified, we would do a lumbar mobilization. So some, usually a grade five thrusting maneuver directed at the lumbosacral region, followed up with some general range of motion and strengthening exercises. So a lot of people with posterior hip pain would fall into this category as having some evidence of this. If we identify posterior hip pathology itself, we would try to identify the structures that are tight with an emphasis on the psoas and short rotators. We would include soft tissue mobilization and then address any weakness through strengthening. Stretching the deep rotators, this would be a position that we would put our patients in, flexion with adduction. We have published some studies, cadaver work, to show the best positions that can stretch the short rotators, and it was found that straight adduction and 90 degrees of hip and knee flexion and 45 degrees of internal rotation and neutral flexion extension were the two positions that best lengthen the short rotators. So particularly the lower picture is one that I give the patient as a home program and the upper picture stretching internal rotation in neutral flexion extension would be one I would do in the clinic. Sciatic nerve glides can be done also as indicated if we think there's sciatic nerve entrapment. So not tensioning the sciatic nerve, but what we would call more flossing the sciatic nerve through the lower extremity, including neck flexion and knee extension. We could also do sciatic nerve mobilization. So this would be something that we'll do in the clinic if I felt the sciatic nerve was being entrapped really at the level of the external rotators. So to perform this, really you're trying to use the greater trochanter neck of the femur to push that sciatic nerve out of the groove and try to eliminate any of that entrapment. So this would be a technique I would perform in the clinic looking for any, you know, hopefully it helped alleviate some of the symptoms. There are also myofascial pain syndromes that can occur. Trigger points, they're commonly referred to as it can be identified in the gluteus minimus and medius as well as the short rotators. So if we identify those, we would do our soft tissue mobilization, strengthening and stretching those structures as appropriate, but they do give a referred pain pattern in that posterior hip region. If going back to the hip spine syndrome, it's also important to identify any potential movement dysfunction that could be caused by poor pelvic and trunk stability. So looking specifically at the glute medius, quadratus laborum, rector spinae and abdominals and how they're functioning. And this would be, you know, similar to scapular stabilization. So most physical therapists are fairly comfortable in treating the shoulder. And when I present this information to them, I make sure they realize this isn't anything new. We do this for most of our shoulder patients already. It would just be something similar we would do for our hip patients, particularly if they had a movement dysfunction or poor neuromuscular control. I think the glute medius can't be underestimated as far as its contribution for dysfunction. So you can see that if there's weakness in the glute medius, there will be some compensations that occur can leading to lumboselvic, lumbopelvic, sacroiliac joint this problem. So, you know, I'm very careful to identify any weaknesses and treat it as it comes about. I think most patients that I see do have some evidence of glute medius weakness that needs to be addressed through a variety of different exercises that can be used to help strengthen that muscle. The quadratus lumborum would be similar to the serratus and lower trap for the pelvis. So we would do some kind of side planking, some bridging exercise to help work on those muscles. We're looking to strengthen the glute medius and maximus. We can go to literature and identify what exercises produce, you know, the maximal output. So the literature suggests that the single leg squat test or single leg squat exercise, the side plank can are good for the glute medius. The glute maximus would be a prone plank with hip extension or a step down. And for the erector spinae, we would call the lower picture a bird dog and good morning. So I would try to include these exercises as appropriate for weakness, you know, any weakness that was identified. The other thing that's important to consider when we work with patients is not just, you know, stretching and strengthening the muscles, but, you know, working on neuromuscular control and understanding the interaction between proprioceptive, your passive structures and your active muscular structures that play a role in functional movement. And we want to do more than just strengthen the patient. We want to improve how they're moving. So including functional exercises that would match the patient's goals, needs and activities, and then trying to make sure that our exercises are meaningful and using muscles in a way that will be similar to the patient's desired activity, whether it be an example of cross country skiing, skating, or golfing. So kind of in summary, we take a look at the various pathologies for posterior hip problem. So we would, this would be on our differential diagnosis list. Our rehabilitation strategies try to use classification based treatment to treat any identified impairments, which would obviously be range of motion and strength deficits. And then we'd also try to correct any movement dysfunctions that we'd identified. So the classification based treatment that I would, that I present to physical therapists would include this classification system here, trying to rule out lumbosacral versus hip, extroverse intraarticular, and then the various causes of intraarticular hip pathology. But it all boils down to trying to get a good, appropriate, prioritized impairment list that would help generate a treatment plan. And then when we would refer to, announce to a physician or surgery would be if we identify non-musculoskeletal disorders. If we can't identify any impairments related to range of motion or strength deficits, or there's no movement system disorder. So if someone comes in, is moving well, has good strength and range of motion from a physical therapy standpoint, we can really offer those folks very little. And then, you know, if we are unable to correct any of these impairments or movement system dysfunctions, you know, over a course of, you know, somewhere around four weeks, maybe a little bit less or a little bit more, depending on how the patient presents, that would also be an indication for surgery. So I want to thank you all for your attention and hope you enjoy the rest of your conference. Thank you.

rehabilitation strategies

indications for surgery

classification-based treatment approach

posterior hip pain

range of motion