Dynamic Snapping of the Hip: Sonographic Evaluation. Adam M. Pourcho DO Swedish Sports Medicine

Transcription

1 Dynamic Snapping of the Hip: Sonographic Evaluation Adam M. Pourcho DO Swedish Sports Medicine

2 Special Thanks Jay Smith, MD

3 Disclosures

4 Objectives Brief review of anatomy of anterior, lateral and posterior hip Understand common causes of snapping anterior lateral and posterior hip Review patient positioning and sonographic evaluation of snapping anterior, lateral and posterior hip

5 Ultrasound is Cool but not as cool as golfing in minnesota

6 Patient position and scanning iliopsoas tendon A RT HIP SAX MED

7 Patient position and scanning iliopsoas tendon RT HIP LAX DIST Balius R., et al (2014)

8 Dynamic Assessment of IP Tendon LT HIP SAX LAT

9 Rectus Femoris Anatomy Direct head originates off AIIS 12mm SAX foot print 26mm LAX foot print Becomes the anterior aponeurosis Indirect head originates off the superior acetabular ridge and often blends with the labrum 17 mm SAX foot print 48 mm LAX foot print becomes central aponeurosis and forms 2/3 rd of the posterior component of the conjoint tendon. Martinoli C., et al (2016)

10 Scanning of Indirect Head RT HIP SAX MED

11 Rectus Femoris Indirect Head Avulsion 22 yo collegiate soccer player felt pop in right hip after kicking ball. Presents with anterolateral hip pain. RT HIP LAX DIST

12 Labral Anatomy 22-55% of groin pain has labral tear present 73% of patients with fraying or tearing have chondral damage, with 94% in same area as tearing Most tears in US are anterior portion of labrum- (avascular zone, radial tears) Most tears in Japan and china are posterior aspect. McCarthy J. et al (2003); Lewis CL., et al (2006); Robertson WJ, et al (2007) Groh MM., et al (2009)

13 Labral Tears The labrum attaches directly to the non-articular side of the thin bony rim of the acetabulum and on the articular side Also indirectly through a zone of calcified cartilage and by merging with the acetabular articular hyaline cartilage through a transition zone of 1 2 mm Average thickness is from 2 to 3 mm thick. The labrum is wider and thinner in the anterior region and thicker in the posterior region. The articular side of labrum can have a sulcus that can be mistaken for pathology(arrow) ANT LABRUM POST LABRUM DIST DIST McCarthy J. et al (2003); Lewis CL., et al (2006); Groh MM., et al (2009); Petersilge C. (2005); Robertson WJ, et al (2007)

14 Acetabular Labral Scanning RT HIP LAX DIST

15 Labral Evaluation- Pitt Fall Para-labral cyst? RT HIP LAX DIST RT HIP LAX DIST

16 Dynamic Labral Evaluation H A RT HIP LAX PROX RT HIP LAX PROX

17 Anterior to Posterior Labral Tear RT HIP LAX DIST

18 Lateral Hip Anatomy Hoffman DF, et al (2017)

19 Dynamic Evaluation of Iliotibial Band RT HIP SAX ANT

20 Snapping Gluteus Maximus- Lateral Slide courtesy of Doug Hoffman, MD

21 Ischiofemoral Anatomy/ Impingement Ischiofemoral impingement is caused by compression of the quadratus femoris muscle between the ischial tuberosity and lesser trochanter. The narrowest ischiofemoral interval, defined as the narrowest distance between the medial cortex of the lesser trochanter and the lateral cortex of the ischial tuberosity. Spencer-Gardner L., et al (2017); Finnoff, J., et al. (2015);Stafford G. Et al (2011)

22 Ischiofemoral Anatomy/ Impingement The largest ischiofemoral space measurement occurred with the hip in abduction and internal rotation (51.8 mm, 95% CI 49.2, 54.5 mm) ~ 5 cm Adduction and external rotation resulted in the narrowest ischiofemoral space measurement (30.8 mm, 95% CI 25.5, 36.0 mm). ~3 cm MRI data suggest anything < 2.5 cm to be significant for ischiofemoral impingement, with signal in quadratus femoris on T2 Finnoff, J., et al. (2015); Tosun O., et al (2012)

23 Dynamic: Scanning for IFI

24 Scanning for Snapping Gluteus Maximus - Posterior

25 Atypical coxa sultans Snapping conjoint tendon over ischial tuberosity Spencer-Gardner LS, Pourcho AM, et al. (2015)

26 Atypical coxa sultans Snapping conjoint tendon over ischial tuberosity Spencer-Gardner LS, Pourcho AM, et al (2015)

27 Questions?

28 References Spencer-Gardner L 1, Bedi A 2, Stuart MJ 1, Larson CM 3, Kelly BT 4, Krych AJ 5. Ischiofemoral impingement and hamstring dysfunction asa potential pain generator after ischial tuber osity apophysealfracture non-union/malunion. Knee Surg Sports Traumatol Arthrosc Jan;25(1): doi: /s Epub 2015 Oct 1 Finnoff JT 1, Bond JR 2, Collins MS 3, Sellon JL 4, Hollman JH 5, Wempe MK 6, Smith J 7. Variability of the Ischiofemoral Space Relative to Femur Position: An Ultrasound Study. PM R Sep;7(9):930-7; quiz 987. doi: /j.pmrj Epub 2015 Mar 12. Spencer-Gardner LS, Pourcho AM, Smith J, Krych AJ. Atypical Coxa Saltans Due to Partial Proximal Hamstring Avulsion: A Case Presentation Highlighting the Role for Dynamic Sonography. PM R Apr 7. pii: S (15) doi: /j.pmrj Stafford G, Villar RN. Ischiofemoral impingement. J Bone Joint Surg Br ;93(10): Tosun O 1, Algin O, Yalcin N, Cay N, Ocakoglu G, Karaoglanoglu M. Ischiofemoral impingement: evaluation with new MRI parametersand assessment of their reliability. Skeletal Radiol May;41(5): doi: /s Epub 2011 Aug 29. McCarthy J, Nable P, Alusio FV, et al. Anatomy, pathologic features and treatment of acetabular labral tears. Clin Orthop Relat Res. 2003;406: Lewis CL, Sahrmann SA. Acetabular labral tears. Phys Ther. 2006;86: Robertson WJ, Kadrmas WR, Kelly BT. Arthroscopic management of labral tears in the hip: a systematic review. Clin Orthop Relat Res. 2007;455:88 92 Groh MM 1, Herrera J. A comprehensive review of hip labral tears. Curr Rev Musculoskelet Med Jun;2(2): doi: /s Epub 2009 Apr 7. Petersilge C. Imaging of the acetabular labrum. Magn Reson Imaging Clin N Am. 2005;13(4):641 52, vi.

29 References Maribel Miguel Carlo Martinoli, I Möller, M Blasi, A Pérez. Quadriceps muscle anatomy Cadaver study. Human anatomy Faculty of Medicine. HSC of Bellvitge. Spain Radiologia DISC, Università di Genova, Italy 8th Muscle Tech NetWork Workshop in Muscle and Tendon Barcelona 3-4 October Balius R 1, Pedret C 2, Blasi M 1, Miguel M 1, Vallejo B 1, Margalet E 1, Bong DA 1, Martinoli C 1. Sonographic evaluation of the distal iliopsoas tendon using a new approach. J Ultrasound Med Nov;33(11): doi: /ultra Hoffman DF 1, Smith J 2. Sonoanatomy and Pathology of the Posterior Band of the Gluteus Medius Tendon. J Ultrasound Med Feb;36(2): doi: /ultra Epub 2016 Dec 31.