hip pathologyw mccormick

2017

mccormickortho.com

overview

• classification

• common hip pathologies• FAI• GT pain• snapping

• workup

• treatments

• sample cases

• rehabilitation

• outcomes/complications

hip pathology classification

• V – Vascular

• I – Inflammatory

• N – Neoplastic

• D – Degenerative / Deficiency

• I – Idiopathic

• C – Congenital

• A – Autoimmune

• T – Traumatic

• E – Endocrine

•mechanical• congenital

• dysplasia• FAI

• acquired• trauma • FAI

• non mechanical• immune• infection• vascular (AVN)

hip pathology classification - anatomic

• groin• adductor muscle• anterior acetabular/labral• fascial disruption

• flexion crease• acetabular/labral• iliopsoas tendon

• C-sign• lateral acetabular/labral

• GT• abductor tendon • IT band (snapping)

• buttock• posterior acetabular/labral• sciatic

mechanical articular hip problems

• single event trauma• dislocations/fractures/labral tears

• think shoulder dislocation

• cumulative trauma• labral tear

• usually in setting of too much/too little bone

• cartilage injury• point loading and shear

mechanical non articular hip problems

• ischiofemoral impingement

• sciatic entrapment

• tendon tears• abductor

• hamstring

• fascial disruption (aka sports hernia etc)

onion layers

• limping

• pain behavior

• muscle activation pattern changes

• GT pain syndrome

• narcotic use

• mis-diagnoses

*beware the young multiple comorbidity patient with symptoms>findings*

common hip pathologies

• labral tear

• GT pain syndrome

• snapping

labral tear

what?

groin pain

flexion

rotation

lock/catch

why?

labral tear – not enough bone (dysplasia)

• bone not providing enough coverage (support) for femoral head

• labrum hypertrophies to provide that support

labral tear – too much bone (FAI)

• at risk anatomy + at risk activity

• wild card• reparative capacity

• young

• active

• at risk activities

FAI – acetabular side (pincer impingement)

• overcoverage

FAI – acetabular side

too much bone everywhere

FAI - acetabular side

too much bone in one area

focal overcoverage

FAI – femoral side – CAM impingement

not enough clearance

AIIS impingement (subspine impingement)

• not enough clearance

• possible history of AIIS avulsion

**flexion crease pain with straight flexion• can be tough to differentiate from anterior overcoverage/ant CAM/ant labral tear

Image from Shibahara, healio 40(4):e725-e728

fascial disruption/core muscle/FAI

• the hip bone’s connected to the back bone…

• restricted motion in hip• demands more motion from low back, pubic symphysis

• puts abdominal fascia/muscles in vulnerable position

Image from Larson cm. sports health 2014. 6(2):139-144

Prevalence

• CT study of 100 joints (50 people) asymp• 39% of hips had at least 1 predisposing factor

• M 48% > F 31%

• 74% of hips aspherical

GT pain syndrome

• abductor tendon tendinopathy/tear

• bursitis

• idiopathic

• **pain with resisted abduction is their usual pain**• pain with high flexion and IR is usually only at GT

snapping - internal

• iliopsoas over anterior acetabular rim• “I can hear it”• anatomy + movement• anatomy

• overcoverage (pushes the labrum into the way)• can also happen with THA

• movement• repetitive high flexion with rotation

• ?compensation for lack of mobility elsewhere?

• iliopsoas release???• maybe in THA• better to treat underlying cause in native joint

snapping external

• “my hip dislocates”

• ITB moving over GT

• “I can see it”

• ITB fenestration???• last resort

Image from aaos orthoinfo external snapping hip

workup – history

FAI Arthrosis Abductor Tear RED FLAGS

episodic episodic but ache at night

episodic +/- ache “all the time”

groin/Csign buttock GT rad below knee

worse with flexionrotation

“loosens up”worse at night

worse with standing/walking

worse with any movement

better with NSAIDs

better with restNSAIDs

better with rest nothing improves it

Image from Dooley Can Fam physician 2008.54(1)42-47

workup – exam

FAI Arthrosis Abductor Tear RED FLAGS

gait normalonly limp when flared

normal to antalgic limp walking aids with little demonstrable pathology

n to low abd. strength

normal +/- pain inhibition

decreased abdstrength

unable to selectively activate glutei

worse with flexionrotation

straight flexion may be painless

pain at GT with resisted abd

unable to flex > 90

GT tenderness is not the usual pain

GT tenderness not common

GT tenderness may be the usual pain

tenderness everywhere

Image from Dooley Can Fam physician 2008.54(1)42-47

workup - tests

routine• screen for bony pathology

• xray (AP pelvis, 45 degree Dunn view, false profile)

FAI• CT with 3D reformats

• screen for occult arthrosis• preop planning

• MRI only if diagnosis uncertain AND your radiologists are experienced• joint injection if multiple pain generators

• caution false negatives

abductor tear• MRI

fascial disruption/core muscle injury• MRI

treatment – non operative/preoperative

• mechanism dependent• abductor and core strengthening

• NSAIDs

• activity modification

• normalize gait/strength

• teach muscle control (vital for postop)

• not everyone with pathology is a surgical candidate• arthrosis may be too advanced• ability to successfully rehab is critical

treatment - operative

• address the underlying cause• undercoverage – PAO

• overcoverage – acetabuloplasty

• AIIS – recession

• CAM – resection

• tendon tear – repair

• fascial disruption – repair

rehabilitation

• phase 1 • manage inflammation

• regain motor control

iliopsoas tendonitis

raw bone surfaces

• phase 2• gait

• strength

emphasis on coordination, proprioception, balance

• phase 3• non-sagittal plane

• endurance

ROM?

internal ok

many are delayed

arthroscopy for FAI - outcomes

• mHHS 62 – 82

• 8 yr survival – 82.6% - M>F, young>old, BMI low>high

• Revision – 5% at 2 yrs• BMI, age, sex

arthroscopy for FAI - complications 8%

• DVT/PE – 0.1%

• Infection – deep 0.04%, superficial 1%

• femoral neck stress fracture – 0.1%

• heterotopic ossification 0.8%

• traction related• perineal numbness 1.4%

• ankle/foot pain 0.8%

• lateral thigh numbness -common postop, 1.6% beyond 6mo

• iatrogenic chondral/labral injury 2%

complications - avoidable

• wrong diagnosis• radiculopathy

• missed secondary diagnosis• fascial disruption

complications - avoidable

• residual deformity/pathology

complications - avoidable

• rehab• too fast

• too slow

• just plain wrong

• unknown• capsular stiffness and inflammation

• poor response to NSAIDs, injections

• adhesions

less common hip pathologies

• ischiofemoral impingement

• sciatic entrapment

• hamstring avulsions

sample case 1 – CAM FAI

sample case 2 - overcoverage

sample case 3 – mixed FAI

• dancer

• postop

where is all this going?

• we have been here before• shoulder

• pick up new diagnoses

• treat them in less invasive ways

• not everything is understood…so not everything has a name/treatment yet• subacromial impingement vs GT pain syndrome

• history and physical are paramount• imaging can lead you astray

• “what can I do?” vs “what should I do?”

• rehab focuses on muscular control• despite being more constrained