GET HIP! CAPA 2015 Annual Conference WHAT IS HIP? HIP JOINT. Bradford H. Stiles, M.D., FAAFP

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1 GET HIP! Bradford H. Stiles, M.D., FAAFP 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 lesser trochanters 1

2 HIP MOTION 6 degrees of motion: flexion, extension, abduction, adduction, internal and external rotation Flexors: iliopsoas, rectus femoris and sartorius (pectineus and tensor fascia latae) Extensors: gluteus maximus, hamstrings (biceps femoris, semimembranosus and semitendinosis); 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, perforatingbranches 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 2

3 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 and cyst formation Etiology is multifactorial (genetics, body habitus, repetitive use, history of trauma) 3

4 Radiographs show narrowing joint line, bone spur formation, cystic changes Treatment aimed at pain reduction NSAIDs/acetaminophen Consider Physical Therapy for strengthening, mobility evaluation in elderly May consider intraarticular corticosteroid injection Ultimate treatment is arthroplasty; delay as long as possible 4

5 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 5

6 FEMOROACETABULAR IMPINGEMENT (FAI) Due to bone overgrowth of either femoral head (cam lesion) or of acetabulum (pincer lesion) Repetitive impingementcan lead to acetabular labrum tears and abnormal wearing of the articular cartilage 3 types of FAI Cam Pincer Combined Becoming more recognizedin 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 arthrogramto assess for labral and cartilage damage Physical therapy can help with symptoms, but often not beneficial Surgical correction (removal of bone spurs, repair/debridementof any associated labral pathology) often required, especially in athletes 6

7 HIP DYSPLASIA From Ancient Greek dys-, bad and plasis, formation Congenital defect Acetabulum does not completely cover the femoral head, creating increased force that is unevenly distributed, leading to abnormal wear Females > Males If diagnosed early enough, can refer for periacetabular osteotomy (PAO) to slow down degenerative changes 7

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9 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 9

10 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-bearingactivity 10

11 Further work-up required if x-rays negative but suspicious history Bone scan can be positive within 24 hours of injury MRI extremely sensitive 11

12 TREATMENT Treatment is dependent on location, compression vs. tension side Nondisplaced compression side stress fractures treated conservatively with NWB until fracture is healed (6-8 weeks); serial radiographs essential to monitor for any worsening 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 and resisted adduction Pain with sit-ups May see changes on x-ray; bone scan and MRI very sensitive 12

13 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 Conservativetreatment 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 13

14 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 corticosteroidinjection HIP POINTER Generic term incorporating both contusions and avulsions of the pelvic rim Treatment is conservativewith ice, NSAIDs, physical therapy and gradual return to activities 14

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16 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 resisted hip external rotation Pace sign: weakness in resisted abduction/externalrotation 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) 16

17 MERALGIA PARESTHETICA Impingementof lateral femoral cutaneous nerve at inguinal ligament Risk factors: tight clothing/work belts, obesity or recent weight gain, pregnancy Sxs: numbness/tinglingin 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 17

18 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 not vaccinated) 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 conservativewith rest, anti-inlammatories Sxs generally resolve spontaneously over 1-2 weeks 18

19 DEVELOPMENTAL DYSPLASIA OF THE HIP (DDH) General term for hip instability/looseness 1-1.5/1,000 births Risk factors: 1 st 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 sand 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 containmentof 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 up with normal hip joint 19

20 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 20

21 QUESTIONS? 21