Instructional Course Lecture Differentiating Hip … · Instructional Course Lecture Differentiating Hip Pathology From Lumbar Spine Pathology: Key Points of Evaluation and Management

Instructional Course Lecture

Differentiating Hip Pathology FromLumbar Spine Pathology: KeyPoints of Evaluation andManagement

Abstract

Thediagnosis and treatment of patientswho haveboth hip and lumbarspine pathologies may be a challenge because overlappingsymptoms may delay a correct diagnosis and appropriate treatment.Common complaints of patients who have both hip and lumbar spinepathologies include low back pain with associated buttock, groin,thigh, and, possibly, knee pain. A thorough patient history should beobtainedanda complete physical examination should be performed inthese patients to identify the primary source of pain. Plain andadvanced imaging studies and diagnostic injections can be used tofurther delineate the primary pathology and guide the appropriatesequence of treatment. Both the surgeon and the patient shouldunderstand that, although one pathology is managed, themanagement of the other pathology may be necessary because ofpersistent pain. The recognition of both entities may help reduce thelikelihood of misdiagnosis, and themanagement of both entities in theappropriate sequence may help reduce the likelihood of persistentsymptoms.

Hip and lumbar spine patholo-gies often occur in combina-

tion, which may result in substantialdisability.1-3 Patients with both hipand lumbar spine pathology com-monly have low back pain (LBP)with associated buttock, groin,thigh, and, possibly, knee pain. Thediagnosis and treatment of thesepatients may be a challenge becauseoverlapping symptoms may delay acorrect diagnosis and, therefore,appropriate treatment.Offierski and MacNab4 originally

described the term “hip-spine syn-drome” in 1983. The authors clas-sified hip-spine syndrome as simple,complex, secondary, or misdiagnosed.In patients with simple hip-spinesyndrome, the primary source of

symptoms is clear despite coexistenthip and lumbar spine pathologies. Inpatients with complex hip-spine syn-drome, however, no clear source ofsymptoms is known despite a detailedphysical examination. Patients withcomplex hip-spine syndrome requireadditional diagnostic tests, includingdiagnostic injections. In patients withsecondary hip-spine syndrome, bothpathologies are interdependent, andthe symptoms of one region are sec-ondary to the pathology of the other.The authors reported that flexioncontracture of the hip that results incompensatory hyperlordosis of thelumbar spine, which causes foraminalstenosis, especially at L3-4, is anexample of secondary hip-spine syn-drome. Similarly, scoliosis that causes

Aaron J. Buckland, MBBS,FRACS

Ryan Miyamoto, MD

Rakesh D. Patel, MD

James Slover, MS, MD

Afshin E. Razi, MD

From the NYU Hospital for JointDiseases, New York, NY (Dr. Buckland,Dr. Slover and Dr. Razi), Fair OaksOrthopaedics, Fairfax, VA(Dr. Miyamoto), and the Department ofOrthopaedic Surgery, University ofMichigan Health System, Ann Arbor, MI(Dr. Patel).

J Am Acad Orthop Surg 2017;25:e23-e34

DOI: 10.5435/JAAOS-D-15-00740

Copyright 2016 by the AmericanAcademy of Orthopaedic Surgeons.

February 2017, Vol 25, No 2 e23

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.

http://dx.doi.org/10.5435/JAAOS-D-15-00740

pelvic obliquity and acetabular tiltmay result in uncovering of the fem-oral head. In patients with mis-diagnosed hip-spine syndrome, theprimary source of pain is incorrectlydiagnosed, which results in inappro-priate, expensive treatment.Unsurprisingly, hip and lumbar

spine pathologies may mimic oneanother. Several studies have reportedon the source of referred hip pain,which includes all lumbar nerve rootsvia the sciatic, obturator, and femoralnerves.5,6 Surgeons should under-stand how to perform a comprehen-sive evaluation of and appropriatelytreat patients with potential hip andlumbar spine pathologies.

History

A thorough patient history is crucialto differentiate hip pathology fromlumbar spine pathology. A thoroughpatient history begins with anassessment of the temporal onset,duration, severity, location, andcharacter of the pain and the ante-cedent trauma. Surgeons must deter-mine whether a patient has pain withactivity, at rest, or both. Pain at nightand the presence or absence of pain-free intervals may indicate a tumor oran infection. Traditionally, groinpain is associatedwith hip pathology,and buttock and back pain is associ-ated with lumbar spine pathology;however, overlap exists between hipand lumbar spine pathologies. Painfrom hip osteoarthritis (OA) can belocalized to the groin (84%), buttock(76%), anterior thigh (59%), poste-rior thigh (43%), anterior knee(69%), shin (47%), and calf(29%).7,8 In general, difficulty with

putting on shoes or getting in andout of a car are associated with hippathology. A burning or electriccharacter to pain may be more sug-gestive of lumbar spine pathology,especially if accompanied by a nerve-root signature or associated numb-ness or weakness. The ability of apatient to ambulate with a forwardposture, which is known as theshopping cart sign, or improvementin pain in a sitting position mayindicate lumbar stenosis. Theinability of a patient to lie on his orher side is likely caused by trochan-teric bursitis rather than lumbarradiculopathy or intra-articular hippathology. Clicking, snapping, orpain with movement of the hip likelyindicates intra-articular hip pathol-ogy. Some patients may describe hippain in which he or she grasps thelateral aspect of the hip with his orher thumb and index finger in thegroin (C-sign). Changes in posturemay highlight potential psoaspathology if pain is felt in the groinand thigh or spinal instability if painis felt in the lower back. A history ofstartup groin pain (ie, pain thatusually improves after 5 to 10 stepsand then gradually returns) mayindicate a loose total hip arthro-plasty (THA) component. Startupback or buttock pain may indicatespinal instability.

Physical Examination

The physical examination of a patientwith potential hip and lumbar spinepathologies should include inspec-tion and palpation of the affectedareas, an observation of gait, anda comprehensive hip and spinal

evaluation. Surgeons should observea patient’s posture, muscle atrophy,previous surgical scars, limb-lengthdiscrepancy, pelvic obliquity, andlower limb and spinal alignment(coronal, sagittal, and rotational). Ifa limb-length discrepancy exists,blocks should be placed under thepatient’s short leg to obliterate pelvicobliquity before observing spinalalignment. The forward bend testshould be performed to assess spinalrotational deformity; in a patient’sattempt to achieve extension, painmay indicate lumbar stenosis orspinal instability. Palpation for areasof tenderness over the greater tro-chanter, sacroiliac joints, groin,buttock, and lumbar spine and evi-dence of step-off between spinousprocesses may be clues to the morelikely pathology. An observation of apatient’s gait may help surgeonsassess for antalgic gait or the pres-ence of an abductor lurch. Walkingon the heels and toes may indicatesubtle weakness as a result of L4through S1 nerve involvement.The Trendelenburg test should beperformed. Although a positiveTrendelenburg test has been re-ported to indicate hip pathology, theTrendelenburg test also may bepositive in patients with L5 radicul-opathy as a result of the innervationof the gluteus medius and minimus.Hip range of motion testing should

be performed, assessing for loss ofinternal rotation with pain at termi-nal range of motion, which indicateship pathology.9-12 Groin pain andthigh pain have been reported in55% and 57% of patients with hippathology, respectively; however,buttock pain and pain distal to the

Dr. Miyamoto or an immediate family member serves as a paid consultant to or is an employee of CONMED Linvatec and has stock or stockoptions held in Tornier. Dr. Patel or an immediate familymember is amember of a speakers’ bureau or hasmade paid presentations on behalf ofStryker Spine, and serves as a paid consultant to or is an employee of Globus Medical and Stryker. Dr. Slover or an immediate family memberhas received research or institutional support from Zimmer Biomet and DJOGlobal. Dr. Razi or an immediate family member serves as a boardmember, owner, officer, or committeemember of the AmericanAcademy of Orthopaedic Surgeons, the AmericanOrthopaedic Association, andthe Brooklyn Orthopaedic Society. Neither Dr. Buckland nor any immediate family member has received anything of value from or has stock orstock options held in a commercial company or institution related directly or indirectly to the subject of this article.

Differentiating Hip Pathology From Lumbar Spine Pathology: Key Points of Evaluation and Management

e24 Journal of the American Academy of Orthopaedic Surgeons


knee have been reported in 71% and22% to 47% of patients with hippathology, respectively.5 The sensi-tivity and specificity of groin pain forhip dysfunction has been reported tobe 84.3% and 70%, respectively. Onphysical examination, patients withpain caused by hip pathology areseven times more likely to have alimp and report groin pain and are14 times more likely to have limitedinternal rotation compared withpatients with pain caused by lumbarspine pathology.9

A thorough neurologic examina-tion of the upper and lower extremi-ties for upper motor neuron signs is

crucial. Several provocative tests canhelp clarify whether symptoms arecaused by hip or lumbar spinepathology (Table 1). Positive pro-vocative tests that likely indicatelumbar spine pathology include thestraight leg raise, contralateralstraight leg raise, and femoral nervestretch tests. Surgeons shouldobserve patients with hip flexioncontracture, which may result in afalse-positive femoral nerve stretchtest. Positive provocative tests thatlikely indicate hip pathology includehip impingement tests, such as theFADIR (flexion, adduction, internalrotation) test or the FABER (flexion,

abduction, external rotation) test;the snapping iliopsoas test; andinstability tests. Compression atthe sacroiliac joint and a positiveFABER test may indicate sacroiliacjoint arthritis.

Diagnostic Tests

Plain radiography is the first-lineimaging modality that should beperformed to determine the likelysource of pathology. AP radiographsof the pelvis and cross-table lateralradiographs should be obtained inpatients in whom hip OA is sus-pected. In addition to standing AP

Table 1

Common Provocative Tests for Hip and Lumbar Spine Pathologies

Provocative Test Description Common Pathologies

Straight leg raise test The examined leg is raised with theknee extended.

Lumbar radiculopathy (lower lumbarnerves), with pain elicited from30� to 60�

Contralateral straight leg raise test The contralateral leg is raised with theknee extended.

Lumbar radiculopathy (lower lumbarnerves), with pain elicited in the other legfrom 30� to 60�

Femoral nerve stretch test With the patient in the supine position,the hip is extended and the knee isflexed.

Lumbar radiculopathy (upper lumbarnerves)

Thomas test In the supine position, the patient grabsone knee and flexes it to the chest.The test is positive if the examinedleg does not extend fully.

Hip flexion contracture of the examinedleg

Ober test With the patient lying on theunaffected side and the knee flexedto 90�, the symptomatic hip isbrought from abduction to adduction.

Iliotibial band tightness

Anterior impingement test(FADIR test)

Hip flexion to 90�, with forced internalrotation and adduction

FAI, labral tear, or piriformis syndromewith groin pain

Posterior impingement test(FABER test)

Hip flexion, abduction, and externalrotation

Sacroiliac joint dysfunction with buttockpain

Intra-articular hip pathology (FAI) withanterior and lateral pain

Seated piriformis stretch test With the patient in a seated position,flexion and adduction with the internalrotation test

A positive test, which recreates posteriorpain at the level of the piriformis orexternal rotators, indicates possiblesciatic nerve entrapment.

Active piriformis contraction test The patient pushes the heel down intothe table, abducting and externallyrotating against resistance as theexaminer monitors the piriformis.

Pain and weakness may indicate sciaticnerve entrapment.

Trendelenburg test With the patient standing on one leg,the opposite hemipelvis drops.

Weakness of gluteus medius on thestanding leg

FABER = flexion, abduction, external rotation; FADIR = flexion, adduction, internal rotation; FAI = femoroacetabular impingement

Aaron J. Buckland, MBBS, FRACS, et al



radiographs of the pelvis, 45�- or90�-Dunn lateral or frog-lateralradiographs of the hip are useful toassess for femoral head asphericity,and false-profile radiographs areuseful to assess for acetabular dys-plasia. Radiographs of the spineshould be obtained with the patientin a standing position, depending onpathology. If lumbar spine pathol-ogy is suspected, AP and lateralradiographs should be obtained;however, lateral flexion-extensionradiographs can help identify insta-bility or spondylolisthesis. If spinalmalalignment is present, 36-inch APand lateral standing radiographsshould be obtained to assess align-ment from the femoral heads to thelower cervical spine.Although MRI and CT can help

differentiate hip pathology from lum-bar spine pathology, they are not first-line imaging modalities. MRIs of thespine can demonstrate nerve-rootcompression, epidural lesions, infec-tion, disk and soft-tissue pathology inthe lumbar spine, and the paraspinalmuscles (including the psoas muscles).MRIs of the hip (6 MRI arthrogramsor delayed gadolinium-enhancedMRIs of cartilage) can demonstratechondrolabral pathology, cartilagelesions, the ligamentum teres, andextra-articular soft-tissue pathology.CT scans of the lumbar spine aid inthe evaluation of fusion, spondylol-ysis, stress fractures, or bony tumorsand can be used in combination withCT myelograms for patients in whomMRI is contraindicated. Three-dimensional CT reconstructions ofthe hip allow surgeons to better assessfor camshaft and pincer deformities,acetabular morphology, and sus-pected femoral neck stress fractures.CT scanograms can be used to assessfor femoral rotational deformities.Care should be taken to correlate apatient’s diagnostic tests with his orher history and physical examinationbecause positive findings increasewith patient age.

If the etiology of a patient’s painremains unclear or coexistent hipand lumbar spine pathologies aresuspected, additional informationmay be required. Electrophysiologicstudies can help differentiate radi-culopathy from peripheral nervedisorders, such as neuropathy, ifother diagnostic tests are equivocal.Normal electrophysiologic findingsdo not eliminate the possibility ofradiculopathy.13,14 Leriche syndrome,which is a form of internal iliac arterystenosis, can result in buttock andthigh pain. In patients with vascularclaudication, symptoms typically arerelieved with standing alone and maybe located below the knees.15 Patientswith vascular claudication may havediminished pulses, skin discoloration,and loss of extremity hair. Vascularstudies, including the ankle-brachialindex, duplex ultrasonography, andmagnetic resonance angiography, canhelp rule out peripheral vascular dis-eases. Selective nerve-root injections(transforaminal), epidural injections,and intra-articular hip injections canbe used as a diagnostic or therapeuticmodality. Hip injections have an 87%sensitivity and a 100% specificity forhip pathology and can help predict thesuccess of surgical interventions suchas THA.16-18 The sensitivity of epidu-ral steroid injections for lumbar spinepathology in the setting of hip-spinesyndrome has been less well defined.6

Differential Diagnosis

The development of differentialdiagnoses for hip, spine, and otherpathologies is based on the principlesof probability and importance (Table2). More common pathologies, suchas hip OA or lumbar radiculopathy,are more probable in patients whohave back and lower extremity pain.However, some pathologies, such astumors, stress fractures, and infections,cannot be missed because they mayresult in substantial consequences,

although these pathologies are lessprobable in patients with back andlower extremity pain.

Hip Pathology

Arthritic Hip PathologyHip OA is diagnosed as either pri-mary or secondary as a result ofentities such as gout, chondrocalci-nosis, or hemochromatosis. Often,hip OA occurs in combination withlumbar stenosis and back pain (Fig-ure 1). Studies have reported thatpatients with persistent back painafter THA who undergo managementof the lumbar spine have improvedsymptoms.19-22 Other studies havereported the resolution of back painafter the management of hip disease inpatients undergoing THA or arthro-scopic hip surgery, such as that for themanagement of a labral tear.23-25

In a study of 25 patients with hipOA and LBP who underwent THA,Ben-Galim et al23 reported improve-ment in both hip and back scores at afollow-up of 2 years. In a retro-spective study of 3,206 patients withhip OA (566 of whom also had LBP)who underwent THA, Prather et al24

reported that, although all of thepatients had improved pain and hipscores, the patients without LBP hadgreater improvement in function andpain relief, incurred fewer medicalcharges per episode of care, andspent fewer days in the hospital perepisode of care compared with thepatients who had LBP. In a study of113 patients with pain extendinginto the back (21%), shin (7%), andcalf (3%) who underwent THA,Hsieh et al26 reported complete painrelief in 110 of the patients within 12weeks postoperatively. In a study of344 patients with hip OA (170 ofwhom also had LBP) who underwentTHA, Parvizi et al25 reported on theresolution of LBP in 66.4% of the170 patients in whom it was notedpreoperatively. Conversely, LBPdeveloped in 20% of the 174




patients in whom it was not notedpreoperatively within 1 year post-operatively, which suggests that themanagement of hip pathology mayexacerbate lumbar spine pathology.In a study of a cohort of patients whohad exacerbated lumbar spinesymptoms after THA, McNamaraet al19 reported improved symptomsin the patients who underwentdecompression. Pritchett27 reportedthat 21 patients with lumbar stenosiswho underwent THA had foot droppostoperatively. Therefore, decom-pression of symptomatic severelumbar stenosis occasionally is rec-ommended before THA.

Nonarthritic Hip Pathology

Femoroacetabular Impingementand Labral TearsFemoroacetabular impingement (FAI)refers to altered geometry of the

proximal femur and/or acetabulum,which leads to a conflict between thefemoral neck and acetabular rim.Long-standing symptomatic FAI mayresult in labral tearsand, subsequently,intra-articular chondral damage andearly-onset OA. Camshaft impinge-ment results from femoral head-neckjunction abnormality, which affectsthe acetabulum. Pincer impingementresults from acetabular overcoverage.Coexistent pathology is common inpatients with FAI.Clohisy et al3 and Burnett et al28

described the standard physicalexamination for patients in whomFAI is suspected, which includes hiprange of motion, anterior impinge-ment (FADIR test), and posteriorimpingement (FABER) tests. Isometricstrength testing and a gait analysis arethe mainstays of a comprehensivephysical examination. Groin pain hasbeen reported in as many as 92% of

patients with FAI, and a positiveanterior impingement test has beenreported in as many as 88% ofpatients with FAI. Lateral hip pain,buttock pain, knee pain, and LBPhave been reported in as many as67%, 29%, 27%, and 23% ofpatients with FAI, respectively.Imaging studies that should be ob-tained in patients in whom FAI issuspected include plain radiographsand MRI arthrograms. Studies havereported that the intra-articularinjection of bupivacaine during mag-netic resonance arthrography is 92%sensitive, 97% specific, and 90%accurate for the diagnosis of FAI.29-32

MRI can be used to assess asphericity(a angle) of the femoral head.

Greater Trochanteric PainSyndromeGreater trochanteric pain syndromeincludes disorders that cause pain

Table 2

Differential Diagnoses for Hip, Spine, and Other Pathologies That May Mimic One Another

Intra-articular HipPathologies

Extra-articular HipPathologies Spinal Pathologies Other Pathologies

Hip osteoarthritis Stress fracture Lumbar stenosis with orwithout spondylolisthesis

Sacroiliac joint pathology

Septic arthritis Greater trochanteric bursitis Lumbar disk herniation Sciatic nerve tumor

Stress fracture Iliotibial band tendinitis Foraminal stenosis Intrapelvic tumors

Osteonecrosis Gluteus medius orgluteus minimus tear

Facet cyst Insufficiency fracture of thesacrum

Failed total hip arthroplasty Iliopsoas tendinitis Nerve-root sheath tumor Peripheral vascular diseases(including Lerichesyndrome)

Labral tear Coxa sultans (internal orexternal snapping hip)

Spondylolysis and isthmicspondylolisthesis

Osteitis pubis

Femoroacetabularimpingement

Piriformis syndrome Iatrogenic causes (ie,misplaced pedicle screw)

Paget disease

Loose bodies (synovialchondromatosis, pigmentedvillonodular synovitis,osteochondritis dissecans)

Subgluteal space syndromes(deep gluteal, hamstringpathology, pudendal nerve,and ischiofemoralimpingement)

Sagittal spinal malalignment Peripheral neuropathy

Chondral damage Adductor strain Psoas pathology (abscess,hematoma, malpositionedhardware, transpsoasapproach)

Shingles

Capsular laxity — — Meralgia paresthetica

Ligamentum teres rupture — — Sports hernia




Figure 1

AP (A) and lateral (B) radiographs of the spine demonstrating pelvic tilt (PT) of 36�, pelvic incidence (PI) of 89�, lumbarlordosis of259�, and pelvic incidence-lumbar lordosis of 30� in a 75-year-old woman who had low back pain with associatedleft groin, lateral thigh, and knee pain. In panel B, the yellow line indicates cervical spine alignment, the blue line indicatesthoracic spine alignment, and the green line indicates lumbar spine alignment. AP radiograph of the pelvis (C) and lateralradiograph of the left hip (D) demonstrating avascular necrosis of the left femoral head with collapse and secondary arthritisof the left hip. Midline sagittal T2-weighted MRI of the lumbar spine (E), left of midline sagittal T2-weighted MRI of the lumbarspine (F), and axial T2-weighted MRI of the lumbar spine through L4-5 (G) showing broad-based disk herniation withmoderate to severe central and lateral recess lumbar stenosis. The patient was diagnosed with left hip osteoarthritis andL4-5 spondylolisthesis in combination with lateral recess and L4-5 foraminal stenosis left of midline. The patient underwenttotal hip arthroplasty of the left hip and had substantial pain relief in her back and lower extremity.




over the lateral hip, including tro-chanteric bursitis, external snappinghip, and gluteus minimus/mediusdysfunction (tendinopathy/tears).Classic findings of greater trochan-teric pain syndrome include painwith palpation over the lateral hip, apositive Ober test, the Trendelen-burg sign, a Trendelenburg gait, andadvanced abductor dysfunction.Hip abduction weakness and painwith resisted external rotation orpain with standing on one leg alsoare key physical examinationfindings of greater trochanteric painsyndrome. In a study of 24 patientswith refractory greater trochantericpain syndrome, Bird et al33 reportedthat gluteus medius tears wereobserved on the MRIs of 45.8% ofthe patients.

Coxa Saltans (Snapping HipSyndrome)Internal snapping syndrome refers tothe abrupt snapping of the iliopsoastendon over the iliopectineal emi-nence as the hip moves from flexioninto extension, which is accompaniedby an audible snap, apprehension,and groin pain. External snappingsyndrome refers to the snapping ofthe iliotibial band over the greatertrochanter as the hip moves fromextension into flexion. External rota-tion of the leg in extension followedbyinternal rotation of the hip as it movesinto flexion can accentuate the snap-ping. Trochanteric bursitis is commonin patients with snapping hip syn-drome as a result of the thickened,tight iliotibial band.

Subgluteal Space SyndromesSubgluteal space syndromes includedeep gluteal syndrome, hamstringpathology, pudendal nerve impinge-ment, and ischiofemoral impinge-ment.34,35 The subgluteal space isbordered by the posterior aspect ofthe femoral neck and is locatedanterior to the gluteus maximus,

lateral to the linea aspera, andmedial to the sacrotuberous andfalciform fascia below the sciaticnotch. Deep gluteal syndromeinvolves sciatic nerve entrapment,which is most commonly caused bythe piriformis and results in diffusebuttock or posterior thigh pain andoccasional radiating symptoms. Apositive seated piriformis stretch testand a positive active piriformiscontraction test are key physicalexamination findings of deep glutealsyndrome. Ischiofemoral impinge-ment refers to the narrowing of theischiofemoral space between thelesser trochanter and the ischialtuberosity. Patients with ischiofe-moral impingement have atypicalgroin and/or posterior buttock pain,and pain in these patients is repro-duced via a combination of hipextension, adduction, and externalrotation. MRIs of patients with is-chiofemoral impingement oftendemonstrate narrowing of the is-chiofemoral space and an abnormalsignal or edema in the quadratusfemoris muscle.36

Stress FracturesStress fractures are classified asinsufficiency fractures or fatiguefractures. The femoral neck is themost common site of stress fractures.A stress fracture should be suspectedin long-distance runners; patientswith metabolic bone diseases;patients being treated with long-termdiphosphate therapy; and patientswho report groin, thigh, or knee pain.Pain in patients with a stress fractureis worse with weight bearing andimproves with periods of rest. Tech-netium TC-99m bone scan and MRIare imaging modalities that are sen-sitive for the diagnosis of stressfractures.

Painful Total Hip ReplacementSeveral unique factors must be con-sidered in patients with pain after

THA. In most of these patients, athorough history with regard to thesurgery, the perioperative period, andthe patient’s recent health; a com-plete physical examination; andappropriate imaging studies willallow surgeons to correctly identifythe source of pain. Early-onset painmay indicate an infection, instabilityof the implant, or heterotopic ossi-fication. Late-onset pain may indi-cate an infection, synovitis,metallosis, osteolysis, instability orloosening of the implant, inadequatehip biomechanics (eg, inadequateoffset, limb-length discrepancy), orsoft-tissue (psoas, rectus femoris)inflammation or impingement. Ace-tabular loosening commonly resultsin groin pain and buttock pain.Thigh and or knee pain may becaused by femoral loosening.Activity-related pain or startup painare caused by component instability.Plain radiographs always are indi-cated in patients with pain afterTHA. Serial radiographs allow sur-geons to assess changes in implantpositioning, which may help isolatethe source of pain. More advancedimaging studies, such as MRI, CT,and nuclear imaging, allow for amore detailed evaluation and shouldbe obtained in patients in whom thesource of pain is unclear. Laboratorystudies (eg, complete blood count,erythrocyte sedimentation rate,C-reactive protein levels) and hipaspiration should be obtained inpatients in whom they are warranted.

Lumbar Spine Pathology

RadiculopathiesRadicular pain may mimic referredhip pain in the groin, thigh, or but-tock. Radiculopathy from the L1through L3 nerve roots is more likelyto mimic referred hip pain in theseareas; however, L5 radiculopathymay result in referred pain in thebuttock, lateral aspect of the hip, andthigh. L5 radiculopathy may mimic




meralgia paresthetica. Radiculo-pathy may occur as a result of severalpathologies, including disk hernia-tion, spondylolisthesis, foraminalstenosis, iatrogenic injury (ie, mis-placed pedicle screw), facet cysts, ornerve sheath tumors. Typically,patientswith radiculopathy report anelectric character to lower extremitypain, which may be worse in a sittingposition, in a standing position, orwith a change in posture; however,the pain may not always have anerve-root signature. Motor weak-ness, sensory deficits, and absentreflexes likely indicate radiculo-pathy rather than hip pathology.The straight leg raise test and thecontralateral straight leg raise testare specific but less sensitive for thediagnosis of radiculopathy fromthe L4 through S1 nerve roots, andthe femoral nerve stretch test is aprovocative test for the diagnosis ofL2 and L3 radiculopathy. Imagingstudies that can be obtained to con-firm radiculopathy includeMRI, CTmyelography, and/or electromyog-raphy. A diagnostic or therapeuticnerve-root block can be performedto further confirm radiculopathy;however, Saito et al6 reportedthat nerve-root blocks mask hippathology by interfering with sen-sory nerve pathways.

Neurogenic ClaudicationNeurogenic claudication can mani-fest as buttock and posterior thighpain with ambulation; however,patients with neurogenic claudica-tion also may have thigh and legaching or heaviness/weakness withambulation, which are symptomssimilar to those of patients with hipOA. Lumbar stenosis, with or with-out spondylolisthesis, is the underly-ing pathology in patients withneurogenic claudication. Vascularclaudication must always be ruledout. Although patients with neu-rogenic claudication may havedecreased ambulation tolerance as a

result of leg pain, patients with lum-bar stenosis can continue to ambulateby leaning forward with an ambula-tory support, which is known as theshopping cart sign. Trochantericbursitis is common in patients withlumbar stenosis and spondylolis-thesis; therefore, it must be consid-ered in the differential diagnosis.

Spondylolysis and IsthmicSpondylolisthesisTypically, spondylolysis occurs inyoung athletes, especially those whoparticipate in sports that requirerepeated hyperextension of the lum-bar spine. Patientswith spondylolysishave unilateral or bilateral LBP thatmay radiate to the buttock. The painmay improve with periods of rest,with bracing, or by avoiding hyper-extension. Oblique lumbar radio-graphs may demonstrate a parsdefect; however, CT often isrequired to confirm a diagnosis ofspondylolysis. Pars defects can beactive or inactive; therefore, techne-tium bone scans or single photonemission CT scans should be ob-tained. Selective injection of a parsdefect can help surgeons determine ifthe lesion is substantial.Isthmic spondylolisthesis refers to

an anterior translation of the ceph-alad vertebra in patients with a parsdefect. Patients with unstable isth-mic spondylolisthesis may reportstartup pain when they first get outof a bed or stand up from a chairthat improves after a period ofwalking. Radiculopathy as a resultof foraminal stenosis is common inpatients with isthmic spondylolis-thesis. Standing, flexion-extensionradiographs of the lumbar spine canaid in the evaluation of subtleinstability.

Sacroiliac Joint PathologyPatients with sacroiliac joint pathol-ogy may have unilateral or bilateralbuttock pain. Typically, pain isworse

with walking down a hill and with atight belt. Physical examinationfindings of sacroiliac joint pathologyinclude tenderness to palpation, painwith compression over the sacroiliacjoint, and a positive FABER test. TheFABER test also may be positive inpatients with posterior chondrola-bral pathology of the hip. A sacroiliacjoint injection can aid in differentiat-ing posterior chondrolabralpathologyof the hip from other hip pathologyand lumbar spine pathology.

Psoas PathologyPsoas pathology can manifest asgroin and thighpain andweakness onhip flexion. Causes of psoas pathol-ogy include psoas abscess, hema-toma, malpositioned devices (ie,pedicle screw), and the transpsoasapproach for lumbar fusion. Patientswith psoas pathology may reportdifficulty in standing up from a chairor pain with full hip extension.Physical examination findings ofpsoas pathology include pain withresisted flexion and a positive psoasstretch test. MRI with contrast andlaboratory tests (eg, erythrocyte sed-imentation rate, C-reactive proteinlevel, complete blood count) are use-ful to assess for a suspected abscess,and CT is useful to assess for malpo-sitioned devices.

Sagittal Spinal DeformityAdult degenerative scoliosis, whichincludes sagittal spine deformity(SSD), is a common pathology thataffects 60% of individuals aged .65years.37 SSD may result in substantialpain and disability.38,39 Hip OA iscommon in many patients with SSD.Although SSD is most commonlydegenerative, it also may result from afracture, Scheuermann kyphosis,spondylolisthesis, iatrogenic flatback,or neuromuscular disorders. Patientswith SSD use several compensatorymechanisms, including lordosis offlexible spine segments, increased




pelvic tilt (posterior tilt), posteriorpelvic shift, and hip and knee flexion,in an attempt to stand in an uprightposition40 (Figure 2). The abnormalmechanics of the gluteal muscles,paraspinal muscles, and quadricepsmay result in back, buttock, and thighpain. A fixed flexion deformity of thehip may prevent a patient from usinghip extension to compensate for SSD.The pelvis is the common vital entityin SSD and hip OA.Pelvic tilt can be measured using

two different methods; however, therelationship of the two methods hasyet to be defined (Figure 3). Pelvic tiltcan be determined by measuring theangle between the anterior pelvicplane (from the anterior superioriliac spine to the pubic symphysis)41

and a vertical line to the floor. Hiparthroplasty surgeons favor thismethod for the measurement ofpelvic tilt because subcutaneouslandmarks of the anterior pelvicplane aid in acetabular componentorientation. However, the accuracyof the anterior pelvic plane has beencalled into question because of var-iable overlying soft tissues. Alterna-tively, pelvic tilt can be determinedby measuring the angle between theplane from the bicoxofemoral axis tothe center of the sacral plate and avertical line to the floor. This methodfor the measurement of pelvic tilt hasbeen reported to correlate with pre-operative and postoperative health-related quality-of-life scores inpatients with adult spine deformity.Spine surgeons aim for ,20� ofpelvic tilt in patients who undergo aspinal realignment procedure.Acetabular anteversion is altered by

the position of the pelvis. A reductionin pelvic tilt (anterior tilt) will func-tionally retrovert the acetabulum.Conversely, an increase in pelvic tilt(posterior tilt) will functionallyantevert the acetabulum.A1� increasein pelvic tilt (posterior tilt) will result ina 0.7� increase in functional acetabu-

lar anteversion42,43 and a nonlinearincrease in functional inclination.Pelvic tilt changes with posture.

Several studies have suggested thatpelvic tilt is similar in the supine andstanding positions; however, this isnot true in patients with SSD, and,therefore, supine radiographs of thepelvis in patients with SSD may notindicate the true functional positionof the pelvis. In a sitting position,pelvic tilt increases approximately22�,44 and acetabular anteversionincreases approximately 15� (Figure4). This increase in acetabular ante-version improves posterior coverageof the femoral head, which reducesthe risk for dislocation and preventsanterior femoroacetabular implantimpingement. Spinopelvic fusioneliminates the flexibility of the lum-bar spine and a patient’s ability toalter pelvic tilt during posturalchanges.45 Similarly, a patient withincreased pelvic tilt as a result of SSDwill have less postural variation inpelvic tilt. Although a fixed flexioncontracture may theoretically pre-vent a patient from increasing pelvictilt to compensate for SSD and resultin decompensation of a patient’sSSD, pelvic tilt has not been reportedto substantially change after THA.46,47

We cannot recommend THA as asurgical method to improve sagittalspine posture.Pelvic tilt and acetabular ante-

version increase as the severity of apatient’s SSD increases. In a study of33 patients (41 hips) with adult spinedeformity who underwent spinaldeformity correction, Buckland et al48

reported that excessive acetabularprosthetic anteversion (.25�) wasobserved on the preoperative standingradiographs of 68% of the hips (Fig-ure 5). Excessive acetabular prostheticanteversion likely accounts for theincreased risk for anterior dislocationin patients with ankylosing spondyli-tis49 and may result in edge-loading,ceramic squeak, and increased bear-ing surface wear. The goal of spinal

deformity correction is to increaselumbar lordosis and reduce pelvic tiltvia instrumentation and fusion. Ace-tabular anteversion decreases as pel-vic tilt decreases (Figure 5). Bucklandet al48 reported that the surgicalrealignment of SSD resulted in a mean

Figure 2

Illustration of a lower extremityshowing how lower limbcompensatory mechanisms that areused by patients who have a sagittalspine deformity are measured. Pelvictilt (PT) is the angle between a linedrawn from the center of the femoralhead to the midpoint of the sacralplate and a vertical line to the floor.Posterior pelvic shift (P shift) is theoffset between a vertical line from theposterosuperior corner of the sacralend plate to the floor and anteriorcortex of the distal tibia. Thesacrofemoral angle (SFA), whichmeasures hip extension, is the anglebetween a line drawn from themiddleof the sacral end plate to the centeraxis of the hip and a line drawn fromthe center axis of the hip to thefemoral axis. The knee flexion angle(KA) is the angle between themechanical axis of the femur and themechanical axis of the tibia. Theankle flexion angle (AA) is the anglebetween the mechanical axis of thetibia and a vertical line to the floor.




decrease in acetabular anteversion of5�; however, the authors reported thatacetabular anteversion can decreaseas much as 23�. The authors also re-ported that an iatrogenic increase inlumbar lordosis of 3.2� or a reductionin pelvic tilt of 1.1� resulted in 1� ofacetabular retroversion.The decision of whether to perform

a spinal realignment procedure orTHA as the initial intervention inpatients in whom hip and lumbarspine pathologies occur in combina-tion is a challenge. A thorough patienthistory should be obtained and acomplete physical examination of thespine and both of the hips should beperformed to identify the primarysource of a patient’s pain. Patientpreferences may guide whether thespine or the hip is managed first. IfTHA is being considered as the initialintervention in a patient withasymptomatic SSD, a pelvic tilt–adjusted acetabular orientation mayhelp avoid excessive prosthetic ante-vertion.50 If a spinal realignmentprocedure is likely to be performed

after THA, the surgeon should con-sider the effect of the spinal surgeryon the orientation of the acetabularcomponent in the preoperative plan-ning for THA. Spinal deformity cor-rection should be performed beforeTHA in patients in whom SSD issubstantial and considerable spinaldeformity correction is required.

Summary

In patients who have back and lowerextremity pain, a systematic patient

history and a comprehensive physicalexamination are necessary to identifythe principal cause of pain. Diagnos-tic imaging studies and injections areused to further define the primarysource of symptoms and guide theappropriate sequence of treatment.Although one pathology is managed,secondary causes of painmay need tobe addressed if symptoms persist. Theidentification of both causes of painmay help reduce the likelihood ofmisdiagnosis and unnecessary treat-ment and, thus, reduce the likelihoodof persistent symptoms.

Figure 4

Lateral radiographs of the pelvis in two different patients demonstrating changesin pelvic tilt (PT) between standing (A and B) and sitting (C and D) positions.Note that, in both patients, pelvic tilt increases in the sitting position as a result ofdecreasing lumbar lordosis (LL); however, the increase in pelvic tilt is different ineach patient.

Figure 3

Lateral radiograph of a pelvisdemonstrating that pelvic tilt (PT) canbe determined by measuring theanterior pelvic plane (APP; denotedin yellow) or the position of thesacrum relative to the center of thehip (denoted in orange).(Reproduced with permission fromBuckland AJ, Vigdorchik J, SchwabFJ, et al: Acetabular anteversionchanges due to spinal deformitycorrection: Bridging the gap betweenhip and spine surgeons. J Bone JointSurg Am 2015;97[23]:1913-1920.)




References

References printed in bold type arethose published within the past 5years.

1. Devin CJ, McCullough KA, Morris BJ, YatesAJ, Kang JD: Hip-spine syndrome. J AmAcadOrthop Surg 2012;20(7):434-442. DOI

2. Byrd JW: Hip arthroscopy: Patientassessment and indications. Instr CourseLect 2003;52:711-719.

3. Clohisy JC, Knaus ER, Hunt DM, LesherJM, Harris-Hayes M, Prather H: Clinicalpresentation of patients with symptomaticanterior hip impingement. Clin OrthopRelat Res 2009;467(3):638-644. DOI

4. Offierski CM, MacNab I: Hip-spinesyndrome. Spine (Phila Pa 1976) 1983;8(3):316-321. DOI

5. Lesher JM, Dreyfuss P, Hager N, KaplanM,Furman M: Hip joint pain referral patterns:A descriptive study. Pain Med 2008;9(1):22-25. DOI

6. Saito J, Ohtori S, Kishida S, et al: Difficultyof diagnosing the origin of lower leg pain in

patients with both lumbar spinal stenosisand hip joint osteoarthritis. Spine (Phila Pa1976) 2012;37(25):2089-2093. DOI

7. Fogel GR, Esses SI: Hip spine syndrome:Management of coexisting radiculopathyand arthritis of the lower extremity. Spine J2003;3(3):238-241. DOI

8. Boden SD, Davis DO, Dina TS, PatronasNJ, Wiesel SW: Abnormal magnetic-resonance scans of the lumbar spine inasymptomatic subjects: A prospectiveinvestigation. J Bone Joint Surg Am 1990;72(3):403-408.

9. Brown MD, Gomez-Marin O, BrookfieldKF, Li PS: Differential diagnosis of hipdisease versus spine disease. Clin OrthopRelat Res 2004;419:280-284. DOI

10. Almeida GP, de Souza VL, Sano SS, SaccolMF, Cohen M: Comparison of hip rotationrange of motion in judo athletes with andwithout history of low back pain.Man Ther2012;17(3):231-235. DOI

11. Van Dillen LR, Bloom NJ, Gombatto SP,Susco TM: Hip rotation range of motionin people with and without low back painwho participate in rotation-relatedsports. Phys Ther Sport 2008;9(2):72-81.DOI

12. Shum GL, Crosbie J, Lee RY: Symptomaticand asymptomatic movement coordinationof the lumbar spine and hip during aneveryday activity. Spine (Phila Pa 1976)2005;30(23):E697-E702. DOI

13. Cho SC, Ferrante MA, Levin KH, HarmonRL, So YT: Utility of electrodiagnostictesting in evaluating patients withlumbosacral radiculopathy: An evidence-based review. Muscle Nerve 2010;42(2):276-282. DOI

14. Mondelli M, Aretini A, Arrigucci U,Ginanneschi F, Greco G, Sicurelli F:Clinical findings and electrodiagnostictesting in 108 consecutive cases oflumbosacral radiculopathy due to herniateddisc. Neurophysiol Clin 2013;43(4):205-215. DOI

15. Nadeau M, Rosas-Arellano MP, Gurr KR,et al: The reliability of differentiatingneurogenic claudication from vascularclaudication based on symptomaticpresentation. Can J Surg 2013;56(6):372-377. DOI

16. Crawford RW, Gie GA, Ling RS, MurrayDW: Diagnostic value of intra-articularanaesthetic in primary osteoarthritis of thehip. J Bone Joint Surg Br 1998;80(2):279-281. DOI

Figure 5

Preoperative (A) and postoperative (B) AP radiographs and preoperative (C) and postoperative (D) lateral radiographs of aspine demonstrating changes in acetabular anteversion after sagittal spine deformity correction. Note that the size of theacetabular ellipse (red oval) in panel A is decreased after deformity correction (B), which indicates decreased anteversion.The ante-inclination of the acetabulum (red angle) in panel C also is decreased after deformity correction (D). (Reproducedwith permission from Buckland AJ, Vigdorchik J, Schwab FJ, et al: Acetabular anteversion changes due to spinal deformitycorrection: Bridging the gap between hip and spine surgeons. J Bone Joint Surg Am 2015;97[23]:1913-1920.)




17. Yoong P, Guirguis R, Darrah R,Wijeratna M, Porteous MJ: Evaluation ofultrasound-guided diagnostic local anaesthetichip joint injection for osteoarthritis. SkeletalRadiol 2012;41(8):981-985. DOI

18. Kleiner JB, Thorne RP, Curd JG: The valueof bupivicaine hip injection in thedifferentiation of coxarthrosis from lowerextremity neuropathy. J Rheumatol 1991;18(3):422-427.

19. McNamara MJ, Barrett KG, Christie MJ,Spengler DM: Lumbar spinal stenosis andlower extremity arthroplasty. J Arthroplasty1993;8(3):273-277. DOI

20. Quintana JM, Escobar A, Aguirre U,Lafuente I, Arenaza JC: Predictors ofhealth-related quality-of-life change aftertotal hip arthroplasty. Clin Orthop RelatRes 2009;467(11):2886-2894. DOI

21. Bischoff-Ferrari HA, Lingard EA, Losina E,et al: Psychosocial and geriatric correlatesof functional status after total hipreplacement. Arthritis Rheum 2004;51(5):829-835. DOI

22. Bohl WR, Steffee AD: Lumbar spinalstenosis: A cause of continued pain anddisability in patients after total hiparthroplasty. Spine (Phila Pa 1976) 1979;4(2):168-173. DOI

23. Ben-Galim P, Ben-Galim T, Rand N, et al:Hip-spine syndrome: The effect of total hipreplacement surgery on low back pain insevere osteoarthritis of the hip. Spine (PhilaPa 1976) 2007;32(19):2099-2102. DOI

24. Prather H, Van Dillen LR, Kymes SM,Armbrecht MA, Stwalley D, Clohisy JC:Impact of coexistent lumbar spine disorderson clinical outcomes and physician chargesassociated with total hip arthroplasty. SpineJ 2012;12(5):363-369. DOI

25. Parvizi J, Pour AE, Hillibrand A,Goldberg G, Sharkey PF, Rothman RH:Back pain and total hip arthroplasty: Aprospective natural history study. Clin OrthopRelat Res 2010;468(5):1325-1330. DOI

26. Hsieh PH, Chang Y, Chen DW, Lee MS,Shih HN, Ueng SW: Pain distribution andresponse to total hip arthroplasty: Aprospective observational study in 113patients with end-stage hip disease.J Orthop Sci 2012;17(3):213-218. DOI

27. Pritchett JW: Lumbar decompression totreat foot drop after hip arthroplasty. ClinOrthop Relat Res 1994;303:173-177.

28. Burnett RS, Della Rocca GJ, Prather H,CurryM,MaloneyWJ, Clohisy JC: Clinicalpresentation of patients with tears of theacetabular labrum. J Bone Joint Surg Am2006;88(7):1448-1457. DOI

29. Toomayan GA, Holman WR, Major NM,Kozlowicz SM, Vail TP: Sensitivity of MRarthrography in the evaluation ofacetabular labral tears. AJR Am JRoentgenol 2006;186(2):449-453. DOI

30. Czerny C, Hofmann S, Neuhold A, et al:Lesions of the acetabular labrum: Accuracyof MR imaging and MR arthrography indetection and staging. Radiology 1996;200(1):225-230. DOI

31. Byrd JW, Jones KS: Diagnostic accuracy ofclinical assessment, magnetic resonanceimaging, magnetic resonance arthrography,and intra-articular injection in hiparthroscopy patients. Am J Sports Med2004;32(7):1668-1674. DOI

32. Martin RL, Irrgang JJ, Sekiya JK: Thediagnostic accuracy of a clinicalexamination in determining intra-articularhip pain for potential hip arthroscopycandidates. Arthroscopy 2008;24(9):1013-1018. DOI

33. Bird PA, Oakley SP, Shnier R, KirkhamBW: Prospective evaluation of magneticresonance imaging and physicalexamination findings in patients withgreater trochanteric pain syndrome.Arthritis Rheum 2001;44(9):2138-2145.DOI

34. Martin HD, Kivlan BR, Palmer IJ, MartinRL: Diagnostic accuracy of clinical tests forsciatic nerve entrapment in the glutealregion. Knee Surg Sports TraumatolArthrosc 2014;22(4):882-888. DOI

35. Martin HD, Shears SA, Johnson JC,Smathers AM, Palmer IJ: The endoscopictreatment of sciatic nerve entrapment/deepgluteal syndrome. Arthroscopy 2011;27(2):172-181. DOI

36. Stafford GH, Villar RN: Ischiofemoralimpingement. J Bone Joint Surg Br 2011;93(10):1300-1302. DOI

37. Schwab F, Dubey A, Gamez L, et al: Adultscoliosis: Prevalence, SF-36, and nutritionalparameters in an elderly volunteerpopulation. Spine (Phila Pa 1976) 2005;30(9):1082-1085. DOI

38. Schwab FJ, Blondel B, Bess S, et al:Radiographical spinopelvic parameters anddisability in the setting of adult spinaldeformity: A prospective multicenteranalysis. Spine (Phila Pa 1976) 2013;38(13):E803-E812. DOI

39. Protopsaltis T, Schwab F, Bronsard N,et al: TheT1 pelvic angle, a novelradiographic measure of global sagittaldeformity, accounts for both spinalinclination and pelvic tilt and correlateswith health-related quality of life. J Bone

Joint Surg Am 2014;96(19):1631-1640.DOI

40. Diebo BG, Ferrero E, Lafage R, et al:Recruitment of compensatory mechanismsin sagittal spinal malalignment is age andregional deformity dependent: A full-standing axis analysis of key radiographicalparameters. Spine (Phila Pa 1976) 2015;40(9):642-649. DOI

41. Lewinnek GE, Lewis JL, Tarr R, CompereCL, Zimmerman JR: Dislocations aftertotal hip-replacement arthroplasties. J BoneJoint Surg Am 1978;60(2):217-220.

42. Lembeck B,Mueller O, Reize P,Wuelker N:Pelvic tilt makes acetabular cup navigationinaccurate. Acta Orthop 2005;76(4):517-523. DOI

43. Maratt JD, Esposito CI, McLawhorn AS,Jerabek SA, Padgett DE, Mayman DJ:Pelvic tilt in patients undergoing totalhip arthroplasty: When does itmatter? J Arthroplasty 2015;30(3):387-391. DOI

44. Philippot R, Wegrzyn J, Farizon F, FessyMH: Pelvic balance in sagittal andLewinnek reference planes in the standing,supine and sitting positions. OrthopTraumatol Surg Res 2009;95(1):70-76.DOI

45. Lazennec JY, Brusson A, Rousseau MA:Lumbar-pelvic-femoral balance on sittingand standing lateral radiographs. OrthopTraumatol Surg Res 2013;99(1 suppl):S87-S103. DOI

46. Blondel B, Parratte S, Tropiano P, Pauly V,Aubaniac JM, Argenson JN: Pelvic tiltmeasurement before and after total hiparthroplasty. Orthop Traumatol Surg Res2009;95(8):568-572. DOI

47. Murphy WS, Klingenstein G, Murphy SB,Zheng G: Pelvic tilt is minimally changed bytotal hip arthroplasty. Clin Orthop RelatRes 2013;471(2):417-421. DOI

48. Buckland AJ, Vigdorchik J, Lafage R, et al:Paper No. 85. Acetabular anteversionchanges in spinal deformity correction:Implications for hip and spine surgeons.22nd International Meeting on AdvancedSpine Techniques, Kuala Lumpur,Malaysia, July 8-11, 2015.

49. Tang WM, Chiu KY: Primary total hiparthroplasty in patients with ankylosingspondylitis. J Arthroplasty 2000;15(1):52-58. DOI

50. Babisch JW, Layher F, Amiot LP: Therationale for tilt-adjusted acetabular cupnavigation. J Bone Joint Surg Am 2008;90(2):357-365. DOI




Documents

Instructional Course Lecture Differentiating Hip … · Instructional Course Lecture Differentiating Hip Pathology From Lumbar Spine Pathology: Key Points of Evaluation and Management