Hip Pain in Adults: Evaluation 67th Annual McGill Refresher Course for Family Physicians Dec6/2016

Hip Pain in Adults: Evaluation 67th Annual McGill Refresher Course for Family Physicians Dec6/2016 David J Zukor MD FRCSC Chief Department of Orthopedic Surgery SMBD-Jewish General Hospital Associate Professor Surgery McGill University Montreal

Faculty/Presenter Disclosure Dr David J Zukor I have no disclosures

Disclosure of Commercial Support None received for this program No Conflicts of Interest

N/A Mitigating Potential Bias

Review: Common adult hip problems (ahp) Relevant: H&P Imaging studies Objectives

Outcomes Be able to apply this knowledge to develop an approach to the assessment of ahp s Feel comfortable to: Perform an appropriate H&P Order appropriate imaging studies and ancillary tests

Hip Pain Important / prevalent problem Affects about 15% (8-20%) esp. > 60 yo Family MD s q 1-2 wk.6% of office visits 1/164 cases

Hip Pain Leads to substantial in HR QOL especially in the elderly: Physical Function ADL s / stairs Pain

Etiology Extra-articular: Intra-articular: Bursitis Muscular/Tendon IT band Contusion/strain Referred Arthritis (OA/inflammatory) AVN Fracture Mechanical e.g. labrum, loose bodies

Remember that the hip can be an important source of referred pain to the knee (Obturator nerve) Pain can also be referred to the hip

Anatomy

Anatomy

History Age / General health Occupation Activities / level Past hx (gen. and hip ) Onset Trauma Aggravating / relieving factors Location Groin / anterior thigh Lateral Posterior / buttock

History Focus on FUNCTION! Work Leisure Dwelling Be open minded!

History Activities (especially how they are interfered with i.e. what they can no longer do?) Quality of Life Many QOL scoring systems providing more objective data are easily available (PRO s)

Physical Exam Gait / standing Observe LLD / Pulses Palpation ROM (NB IR, Abduction) Special Trendelenburg Log roll FABER (Flex, ABd,ER) FADIR (Flex,Add,IR) Ober SLR

Physical Exam Can you reproduce the patient s symptoms with the exam?

Physical Exam Observe Deformities / contractures Atrophy Leg lengths Pedal pulse

Physical Exam Trendelenburg Patient stands on affected limb Test is positive if contralateral hemi pelvis drops. (T-burg gait - pt tries to avoid this and lurches over the hip on the affected side) Abductor weakness

Physical Exam Trendelenburg Gait

Physical Exam FABER Flexion- ABduction- External Rotation Helps differentiate hip from SI joint as source of pain

Physical Exam FADIR Flexion ADduction- Internal Rotation Impingement test

Physical Exam Ober Test for IT band tightness

Log Roll Physical Exam Positive with intrarticular pathology

Imaging Hip x-ray: PELVIS! AP/Lateral of hip

Imaging

Imaging Cross table lateral vs Frog-leg lateral

Imaging U/S- operator dependent MRI- most sensitive CT- bony detail, # Nuclear Medicine

Imaging MRI Does NOT replace x- rays! Best modality for: Soft tissues ( labrum) Early detection # s, AVN ( extent and contra-lateral hip)? overly sensitive? over used

Diff Dx Anterior: Usually intra-articular C sign Arthritis FAI Labrum Fracture AVN Synovitis / Septic Arthritis

OA Most common diagnosis seen by Family MD s in patients >40 yo (44%)

Inflammatory Arthritis RA, AS, etc Remember IBD

AVN

Trauma Steroids ETOH Metabolic Caisson s Radiation Thrombotic Transplant Idiopathic AVN Etiology

Traumatic AVN Femoral neck # Hip dislocation? Minor trauma Must follow for @ least 2 years

Normal AVN

AVN Staging Stage 0: abnormal MRI (silent hip) Stage 1: abnormal scan (silent hip) Stage 2: non-specific x-ray changes Stage 3: subchondral collapse(crescent sign) Stage 4: femoral head collapse/arthritis Stage 5: arthritic changes both sides of joint

Fracture Femoral Neck Inter/Sub Trochanteric Stress # s Pelvis especially pubic rami Atypical # s with Bisphosphonates (especially pre #) NB if strong index of suspicion and negative x- rays consider MRI,Bone scan

Intertrochanteric Fracture

Atypical Fracture

Atypical Fracture

Labral Tears Usually insidious onset (worse prognosis) 50% have mechanical symptoms + FABER 88% + FADIR 75-96%

Labral Tears Can be difficult to detect even on MRI Addition of MR Arthrography increases sensitivity to 90% (vs 30%)

Mechanical symptoms: Snapping Popping Catching/locking Sharp stabbing pain Can be difficult to diagnose on H&P U/S (dynamic) MRI but remember sensitivity and often specificity

Snapping Hip Often pops are felt by pt but not by MD During physical exam many pops / clicks are normal and not indicative of an intraarticular problem

Snapping Generalisation: Easily audible = Iliopsoas Easily visible = IT band

Lateral; Greater Trochanteric pain syndrome Bursitis IT band Tendonapathy Meralgia Paresthetica Diff Dx

Bursitis Trochanteric most common Usually tender on palpation May respond to topical Rx, injection

Diff Dx Posterior: LS causes SI joint Piriformis syndrome Vascular

L2-S1 innervation Especially L3 (dermatome) LS causes SI joint (FABER test) Anecdotal evidence for trial of intraarticular local anesthetic infiltration to assess contribution of hip joint as source of pain

Hip Pain in Adults : Evaluation Hip Pain Diff Dx Always remember to consider infection/neoplastic etiology if appropriate (CBC,CRP,ESR) Any painful THR is infected until proven otherwise

Review: Common adult hip problems Relevant: H&P Imaging studies Conclusion

Conclusion Be able to apply this knowledge to develop an approach to the assessment of ahp s Feel comfortable to: Perform an appropriate H&P Order appropriate imaging and ancillary tests