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CAPA 2015 Annual Conference

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Bradford H. Stiles, M.D., FAAFP

GET HIP!

WHAT IS HIP?

HIP JOINT

• Synovial ball-and-socket joint

• Articulation between femoral head and acetabulum

• Acetabulum formed by the confluence of pelvis bones (ilium, ischium and pubis)

• Proximal femoral structures are femoral head, femoral neck, greater and lessertrochanters


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HIP MOTION

• 6 degrees of motion: flexion, extension, abduction, adduction, internal and externalrotation

• Flexors: iliopsoas, rectus femoris and sartorius (pectineus and tensor fascia latae)

• Extensors: gluteus maximus, hamstrings (biceps femoris, semimembranosus andsemitendinosis); posterior portion of adductor magnus

• Abductors: gluteus medius and minimus, tensor fascia latae

• Adductors: adductor longus, brevis and magnus, gracilis and pectineus

• External rotators: piriformis, gemelli, obturator internus/externus, quadratus femoris

• Internal rotators: no pure internal hip rotators

BLOOD SUPPLY

• Acetabulum blood supply is generous

• Femoral head blood supply is tenuous

• Supplied by small, perforating branches of capsular arterial retinaculum

• Increased risk of avascular necrosis (AVN)

HISTORY

• Always obtain a good history

• “If you listen long enough, the patient will tell you the diagnosis.” (Sir William Osler)

• Acute vs. Chronic (Injury vs. Overuse)

• Mechanism of injury (MOI)

• Location of pain (groin, lateral, posterior, thigh, radiation)

• Aggravating factors

• Note age of the patient

• Do not forget about referred pain

• Lumbar spine issues can refer to the groin

• Intraarticular hip issues can refer to distal thigh and knee


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EXAM

• Exam begins with stance & gait evaluation

• Range of motion (ROM) compared side-to-side

• Muscle strength testing in all directions; note any reproduction of pain

• Check for leg length discrepancy

INTRAARTICULAR HIP ISSUES

HIP OSTEOARTHRITIS

• Gradual onset of pain

• Pain in groin

• Wearing/loss of articular cartilage leads to degenerative changes with osteophyte andcyst formation

• Etiology is multifactorial (genetics, body habitus, repetitive use, history of trauma)


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• Radiographs show narrowing joint line,bone spur formation, cystic changes

• Treatment aimed at pain reduction

• NSAIDs/acetaminophen

• Consider Physical Therapy forstrengthening, mobility evaluation inelderly

• May consider intraarticularcorticosteroid injection

• Ultimate treatment is arthroplasty;delay as long as possible


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HIP DISLOCATION

• Acute injury (in adults)

• Posterior >> Anterior

• Posterior: flexion, adduction, internal rotation

• Anterior: slight flexion, abduction, external rotation

• May have associated pelvic fracture

• Requires prompt orthopedic evaluation

POSTERIOR HIP DISLOCATION

ANTERIOR HIP DISLOCATION


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FEMOROACETABULAR IMPINGEMENT (FAI)

• Due to bone overgrowth of either femoral head (cam lesion) or of acetabulum (pincerlesion)

• Repetitive impingement can lead to acetabular labrum tears and abnormal wearing of thearticular cartilage

• 3 types of FAI

• Cam

• Pincer

• Combined

• Becoming more recognized in athletic population

FAI EVALUATION & TREATMENT

• Positive FADIR (Flexion, ADduction, Internal Rotation) test

• Hip x-rays to assess for cam and/or pincer lesion and for advanced degenerative changes

• MR arthrogram to assess for labral and cartilage damage

• Physical therapy can help with symptoms, but often not beneficial

• Surgical correction (removal of bone spurs, repair/debridement of any associated labralpathology) often required, especially in athletes


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HIP DYSPLASIA

• From Ancient Greek dys-, “bad” and plasis, “formation”

• Congenital defect

• Acetabulum does not completely “cover” the femoral head, creating increased force that isunevenly distributed, leading to abnormal wear

• Females > Males

• If diagnosed early enough, can refer for periacetabular osteotomy (PAO) to slow downdegenerative changes


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EXTRAARTICULAR HIP ISSUES

GROIN PAIN

• DDx of groin pain is extensive

• Intraarticular process

• Simple muscle/tendon strain

• Deep bursitis (iliopsoas)

• Femoral neck stress fracture

• Osteitis pubis

• Mass/tumor

• Hernia (inguinal, femoral)

• Nerve entrapments

• GU process

• Referred SI/L-spine pain

• History plays key role in focusing the DDx

• Any history of trauma?

• Sudden onset vs. gradual onset

• Age of patient

• Any change in activity, increase in activity/training

• Past medical history (remote trauma, hx of cancer)

• Any associated sxs (GU, GI, constitutional, etc.)

• Exact location of pain and any radiation of pain

• Is pain activity related and if so, is it immediate or delayed


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HIP FLEXOR STRAIN

• Generic term

• Simple muscle/tendon/ligament strain

• Most common cause of groin pain in athletic population

• Conservative treatment with relative rest, rehab

ILIOPSOAS BURSITIS

• Lies just anterior to hip joint

• More common in those with underlying arthritis

• Pain with hip extension, may cause shortened gait

• May have point tenderness

• Consider US or MRI if diagnosis is unclear

• Rx with NSAIDs, physical therapy

• Recalcitrant cases may require image guided injection

FEMORAL NECK STRESS FRACTURE

• Often misdiagnosed or missed

• Extreme risk of displacement

• Result of overuse/repetitive stress

• Common in athletes, military recruits

• History of recent increased activity (frequency or intensity)

• Tension vs. Compression side

• Must get x-rays if suspicious; may take 2-4 weeks for x-rays to be positive

• Usually present with groin pain or anterior thigh pain with any weight-bearing activity


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• Further work-up required if x-rays negative but suspicious history

• Bone scan can be positive within 24 hours of injury

• MRI extremely sensitive


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TREATMENT

• Treatment is dependent on location, compression vs. tension side

• Nondisplaced compression side stress fractures treated conservatively with NWBuntil fracture is healed (6-8 weeks); serial radiographs essential to monitor for anyworsening

• All tension side stress fractures are treated surgically

OSTEITIS PUBIS

• Repetitive stress at symphysis pubis

• Muscle imbalance with stronger hip flexors/adductors (soccer, skating)

• More common in younger population (< 30 years old) due to more mobility of symphysis

• Tenderness to direct palpation; reproduction of pain with resisted straight leg raise andresisted adduction

• Pain with sit-ups

• May see changes on x-ray; bone scan and MRI very sensitive


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OSTEITIS PUBIS - TREATMENT

• Acutely rest, ice, NSAIDs

• Physical therapy to address biomechanical issues

• Corticosteroid injection rarely

• Gradual return to play

SPORTS HERNIA

• Chronic groin pain due to weakness/injury of the posterior inguinal wall/conjoined tendon

• Often considered an “early direct inguinal hernia”; difficult to diagnose

• Much more common in soccer players

• Conservative treatment often not successful; ultimate treatment is surgery

“SNAPPING HIP”

• Internal vs. external

• Internal: iliopsoas as it crosses iliopectineal line (can also be sign of labral tear)

• External: IT band as it crosses greater trochanter

• Treatment is rehab, rehab, rehab


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TROCHANTERIC BURSITIS

• Common in runners; overuse injury

• Often from underlying IT band tightness

• Point tender on greater trochanter; pain with active abduction; may have snapping

• Direct therapy to IT band stretching (foam roller)

• May require corticosteroid injection

“HIP POINTER”

• Generic term incorporating both contusions and avulsions of the pelvic rim

• Treatment is conservative with ice, NSAIDs, physical therapy and gradual return toactivities


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PIRIFORMIS SYNDROME

SCIATIC NERVE VARIATIONS

PIRIFORMIS SYNDROME

• Sciatic nerve irritation at piriformis

• Can mimic sciatica with pain radiation, but rarely below the knees

• Females > males (6:1)

• Trauma (contusion) vs. overuse

• Cramping/aching pain in buttock

• Reproduction of pain with passive hip flexion/adduction/internal rotation and with resistedhip external rotation

• Pace sign: weakness in resisted abduction/external rotation

• Diagnostic imaging not helpful

• Rehab and piriformis stretching is key to improvement

• Surgical release as a last resort (better results in patients with positive EMG findings)


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MERALGIA PARESTHETICA

• Impingement of lateral femoral cutaneous nerve at inguinal ligament

• Risk factors: tight clothing/work belts, obesity or recent weight gain, pregnancy

• Sxs: numbness/tingling in lateral thigh; may have burning pain

• Treatment aimed at relieving pressure on nerve (looser clothing/belts, weight loss)

• May consider local injection

• Surgery reserved for recalcitrant cases


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THE LIMPING CHILD

• Differential diagnosis is large

• Hip, knee, ankle, foot and intraabdominal pathology

• Hip

• Infection

• Inflammatory (transient synovitis)

• Congenital

• Developmental dysplasia of the hip

• Developmental condition

• Legg-Calve-Perthes

• Slipped capital femoral epiphysis (SCFE)

• Tumor/malignancy

SEPTIC ARTHRITIS

• Usually less than 3 years old

• Group B strep and Haemophilus influenza most common organisms (especially if notvaccinated)

• Sudden onset of pain, usually accompanied by fever and unwillingness to move the joint

• Hip most common joint involved in septic arthritis in children

• Requires hospitalization, IV antibiotics, Orthopedic consultation

TRANSIENT SYNOVITIS OF THE HIP

• Also called “toxic synovitis”

• More common in the 3-10 year old range

• Males: females 2:1

• Onset can be sudden or gradual

• Etiology unknown (? viral)

• Sxs similar to septic arthritis, but usually without high grade fever

• Must rule out more serious conditions

• Treatment is conservative with rest, anti-inlammatories

• Sxs generally resolve spontaneously over 1-2 weeks


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DEVELOPMENTAL DYSPLASIA OF THE HIP (DDH)

• General term for hip instability/looseness

• 1-1.5/1,000 births

• Risk factors: 1st child, female, breech position, family history of DDH, large birth weight

• Barlow and Ortolani tests part of newborn screening; confirm with ultrasound

• In older infants/children, check hip x-ray

• Shenton’s, Hilgenreiner’s and Perkin’s lines

• If diagnosed in first 6 months of life, can treat with bracing

• If diagnosed in older child, surgery generally required

LEGG-CALVE-PERTHES

• Avascular necrosis of femoral head leading to collapse and flattening of femoral head

• Etiology unknown

• Males >> females

• Most common in boys 4 – 10 years old

• Often painless, but will develop limp; easily diagnosed on x-ray

• Goal of treatment is containment of femoral head in acetabulum

• Bracing

• Physical therapy

• Blood supply generally returns over several months, leading to new bone growth

• In children under age 6 years old with appropriate treatment, greater chance of ending upwith normal hip joint


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SLIPPED CAPITAL FEMORAL EPIPHYSIS (SCFE)

• Femoral head slips inferior and posterior to femoral neck

• Incidence 2/100,000 children; may be bilateral (20-40%)

• More common in boys (mean age 13 years) than females (mean age 11 years)

• Associated with period of rapid growth, obesity

• Highest risk group is African-American boys

• Present with painful limp; pain usually in groin but may be in anterior thigh or knee(referred pain)

• Radiographic diagnosis

• Klein’s line

• Surgery required


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QUESTIONS?

Download - GET HIP! - Amazon Simple Storage Services3-us-west-2.amazonaws.com/capa-wp/wp-content/uploads/2016/10/... · GET HIP! WHAT IS HIP? ... • Extensors: gluteus maximus, hamstrings

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