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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?