HIP INJURY Lúnasa 2013 MEDICAL, SCIENTIFIC AND WELFARE COMMITTEE 1. SLIPPED EPIPHYSIS WHAT IS A SLIPPED FEMORAL EPIPHYSIS? The femoral epiphysis is the ball of the hip joint in a child. In this condition, the epiphysis remains in its normal position within the hip socket. However, where the epiphysis joins on to the upper part of the thigh bone (or femur) a weakness in this join allows the affected leg to turn outwards. Children between the ages of 10 and 16 may suffer from this condition which is rather more common in boys than girls. A slip usually occurs slowly (chronic). In this case the child may complain of pain in the groin with exercise or sporting activity. The pain may settle with rest but is normally accompanied by a limp. Less commonly a limp or odd walk may be the only abnormality present. A few children only complain of pain in the knee. This is due to the fact that the same nerves supply both the hip and the knee. If symptoms have been present for some time, the affected leg will be turned outwards, and shortening of the leg may also be present. Sometimes there is a sudden increase in the slip after a period of gradual slipping (acute on chronic). Pain is then more severe and the child will have difficulty walking. More rarely, the slip occurs suddenly (acute). In this case the child is in severe pain and is quite unable to walk. In about one case in three, both hips are affected. HOW DOES A SLIPPED FEMORAL EPIPHYSIS OCCUR? A slip occurs because the join (or growth plate) between the epiphysis and the rest of the thigh bone cannot stand up to the stress placed upon it. It is particularly vulnerable during the rapid growth of adolescence. A minor fall may cause acute, or acute on chronic slipping. WHY DOES A SLIPPED FEMORAL EPIPHYSIS OCCUR? The thickness of the growth plate is affected by various hormones. There is normally a balance between sex hormones and growth hormones. A change in hormone balance may occur during the adolescent growth spurt, particularly if puberty is delayed. Obesity and an underactive thyroid gland also predispose a child to this condition. Once growth of the child ceases, the join fuses and the condition is halted. Page 1 of 10
TREATMENT INVOLVED FOR A SLIPPED FEMORAL EPIPHYSIS A child with a slipped epiphysis is admitted to hospital straight away. Traction with weights pulling on Elastoplast tapes stuck onto the leg is usually used initially but surgery is almost always necessary. The type of operation depends both on the amount of slip and the speed of onset. In most cases the epiphysis can be pinned in the slipped position. This is a comparatively minor procedure. Insertion of pins between the epiphysis and the thigh bone prevents further slipping and tends to cause the growth plate to fuse. If a very acute major slip occurs, then it is sometimes necessary to replace the epiphysis in position: pinning is carried out in addition. This is a more major procedure. If severe deformity has occurred due to chronic slipping, a realignment operation (osteotomy) may be carried out. All surgery is performed under a general anaesthetic. Pinning requires only one or two small incisions on the upper thigh. Recovery afterwards is rapid, and walking is allowed partially weight bearing with crutches. Hospital stay is about 3 to 4 days. Crutches are usually required for 4 to 6 weeks. Open repositioning of the epiphysis or osteotomy requires a longer incision on the side of the thigh. Hospital stay is usually at least 2 weeks in this case. Crutches are then required for up to 3 months. DURING TREATMENT FOR A SLIPPED FEMORAL EPIPHYSIS General complications of surgery are rare in children. Infection of the wound occurs occasionally. The position of the pins may not be ideal, particularly if there is a major slip. This may result in persisting pain. Re-operation is sometimes necessary. Normally pain, limp and turning out of the leg rapidly settle after pinning. Visits to the specialist and x-rays are needed at regular intervals until growth ceases. Following this, the pins are removed. Early medical advice should be sought if any pain or a limp affects the opposite leg. If your child is very young at the time of treatment, the capital epiphysis can grow off the pin. This should normally be picked up during routine follow-up. If not, then the child may experience a return of symptoms. Replacement of the pins with longer ones is necessary in this situation. After a major acute slip, the bone of the epiphysis may be deprived of its blood supply (avascular necrosis). Persisting pain and stiffness accompany this complication and early arthritis commonly follows. Damage to the cartilage of the joint surfaces can also occur. This is also associated with major slips and surgical replacement of the epiphysis. Stiffness is the main result of this complication, and early arthritis usually follows. There is an increased risk of degenerative arthritis in later life following this condition. However, it usually only occurs following complications, or when there has been a large degree of slip. Page 2 of 10
IF A SLIPPED FEMORAL EPIPHYSIS IS LEFT UNTREATED Untreated, the slip is likely to progress and produce severe deformity. An acute major slip may occur with an increased risk of serious complications. Early diagnosis and treatment of this condition is extremely important. Any symptoms occurring in the opposite hip following treatment should be investigated urgently. 2. MERALGIA PARESTHETICA MeMeralgia paresthetica is a condition characterized by tingling, numbness and burning pain in the outer part of your thigh. The cause of meralgia paresthetica is compression of a nerve the lateral femoral cutaneous nerve that supplies sensation to the skin surface of your upper leg. Common causes of this nerve compression include tight clothing, obesity or weight gain, and pregnancy. Meralgia paresthetica can also be due to nerve injury, from a disease such as diabetes or from trauma. Treatment for meralgia paresthetica is directed at relieving the compression and usually consists of self-care measures, such as wearing looser clothing or losing weight. In severe cases of meralgia paresthetica, treatment may include medications to treat the discomfort or, rarely, surgery. SYMPTOMS Pressure on the lateral femoral cutaneous nerve, which supplies sensation to your upper leg, may cause the following symptoms of meralgia paresthetica: Tingling and numbness in the outer part of your thigh Burning pain in or on the surface of the outer part of your thigh Less commonly, dull pain in the groin area or across your buttocks These symptoms commonly occur only on one side of your body and may intensify after walking or standing CAUSES Meralgia paresthetica occurs when the lateral femoral cutaneous nerve a nerve that supplies sensation to the surface of your upper leg becomes compressed, or "pinched." In most people, this nerve passes through the groin to the upper thigh without trouble. But in meralgia paresthetica, the lateral femoral cutaneous nerve becomes trapped often under the inguinal ligament, which runs along your groin from your abdomen to your upper thigh. Common causes of this compression include any condition that increases pressure on the groin, including: Page 3 of 10
Tight clothing Obesity Pregnancy Scar tissue near the inguinal ligament, due to injury or past surgery Walking, cycling or standing for long periods of time Nerve injury, such as due to diabetes or seat belt injury following a motor vehicle accident, also can cause meralgia paresthetica WHEN TO SEEK MEDICAL ADVICE See your doctor if you experience the symptoms of meralgia paresthetica including tingling, numbness or burning pain in the outer part of your thigh. TESTS AND DIAGNOSIS In most cases, your doctor can make a diagnosis of meralgia paresthetica based on your medical history and a physical examination. He or she may touch the affected leg, ask you to describe the pain, and ask you to trace out the specific location of the numb or painful area on your leg. In order to rule out other conditions, your doctor may recommend: X-ray imaging. This diagnostic tool uses electromagnetic radiation to make images of your hip and pelvic area. Electromyography (EMG) This test measures the electrical discharges produced in muscles to help evaluate and diagnose muscle and nerve disorders. During the test, a thin needle electrode is placed into the muscle to record electrical activity. This test is normal in meralgia paresthetica, but may be needed to exclude other disorders when the diagnosis isn't clear. Nerve conduction study. In this test, patch-style electrodes are placed on your skin to stimulate the nerve with a mild electrical impulse. The electrical impulse helps diagnose damaged nerves. Treatments and drugs Treatment for meralgia paresthetica is directed at relieving compression of the nerve, which may include self-care measures, such as wearing looser clothing or losing weight. These conservative measures are effective for most people, with pain usually going away on its own within a few Page 4 of 10
months. Mild pain relievers, or nonsteroidal anti-inflammatory medications, may be helpful if you have bothersome pain. 3. HIP BURSITIS Hip bursitis is a common problem that causes pain over the outside of the upper thigh. A bursa is a fluid filled sac that allows smooth motion between two uneven surfaces. For example, in the hip, a bursa rests between the bony prominence over the outside of the hip (the greater trochanter) and the firm tendon that passed over this bone. When the bursal sac becomes inflamed, each time the tendon has to move over the bone, pain results. Because patients with hip bursitis move this tendon with each step, hip bursitis symptoms can be quite painful. WHAT CAUSES HIP BURSITIS? Hip bursitis can be associated with different types of patients: Athletes Hip bursitis is commonly seen in runners or athletes who participate in running-oriented sports (e.g. soccer, football, etc.). Injuries Hip bursitis is sometimes associated with patients who fall onto their upper thigh, causing a socalled traumatic bursitis. The symptoms are similar to a hip pointer. Post-surgical Patients who have had surgery, such as hip fracture surgery, or total hip replacement, may complain of pain over the outside of the hip. These symptoms are often due to irritation to the bursa causing hip bursitis. HOW IS HIP BURSITIS DIAGNOSED? The diagnosis of hip bursitis is made most reliably on physical examination. The most common symptoms of hip bursitis include: Tenderness over the bony prominence of the upper/outer thigh Swelling over the bursa An x-ray is often obtained to ensure there are no bone spurs or calcifications that could be contributing to the problem. o Occasionally, your doctor may obtain an MRI if the diagnosis is unclear or if the problem does not resolve with treatment. Page 5 of 10
WHAT ELSE CAN CAUSE SYMPTOMS SIMILAR TO HIP BURSITIS? As with any medical condition, other problems that can cause similar symptoms should be considered. Hip bursitis is usually a clear diagnosis, and the symptoms can be distinguished from other conditions. However, some cases of hip bursitis can be confused with other medical conditions. These include: Iliotibial band tendonitis Meralgia paresthetica Low-back conditions These are the most common causes of pain over the upper/outer thigh, other than hip bursitis. Other causes of pain in this area include hip joint problems, such as arthritis and labral tears, but these usually cause symptoms in areas other than the outside of the thigh. TREATMENT The best treatment for hip bursitis, or any form of bursitis, is aimed at controlling the inflammation caused by this condition. As with any treatment program, always talk with your doctor before initiating any specific treatments. The general treatment of hip bursitis consists of: Rest This usually means a period of time not participating in sports or activities that aggravate your symptoms. As a general rule of thumb, any activity that causes hip bursitis pain should be avoided--this only contributes to inflammation of the bursa. Anti-inflammatory Medications Anti-inflammatory medications will help control the inflammation associated with hip bursitis. These medications are helpful for the pain as well as diminishing inflammation. Ice the Injury Icing the area of hip bursitis often helps to alleviate the symptoms of hip bursitis. Especially after exercise, ice can control inflammation, and stimulate blood flow to the injured area. Aspiration/Drainage of the Bursa In some patients who have a significant amount of fluid that has collected within the bursa, a needle can be placed into the bursa to remove the fluid. This is rarely needed in cases of hip bursitis, but when it is done it may be combined with a cortisone injection (see below). Page 6 of 10
Cortisone Injection A cortisone injection may also be given into the bursa in patients with pain. The cortisone injection is helpful because it can be both diagnostic and therapeutic. In cases where hip bursitis may be one of several diagnoses being considered, cortisone can be given to see if the shot helps to alleviate symptoms. Once the initial symptoms are controlled, some physiotherapy strengthening and stretching exercises may be helpful. Physiotherapy Working with a physiotherapist is a useful treatment adjunct for patients with hip bursitis. Not only can the therapist help develop a proper stretching and exercise program, but they can use modalities such as ultrasound which may be helpful as well. Stretching Most patients find relief with stretching of the muscles and tendons that are found over the outside of the hip, specifically the iliotibial band. The idea is that a better conditioned muscle and tendon will glide more easily and not cause hip bursitis. Special attention to proper stretching technique is important. Is surgery ever necessary for hip bursitis? Surgical treatment for hip bursitis is rarely needed, and most patients who are faithful about treatment get better within about six weeks. Patients who do not rest from their activities until the inflammation subsides often have a return of hip bursitis symptoms. Also, patients who return too aggressively (i.e. not a gradual build-up), may also find that their symptoms return. In those few cases where surgery is needed, this can be done through a small incision, or sometimes it can be performed arthroscopically. Either way, the bursa is simply removed (called a bursectomy), and the patient can resume their activities. The surgery is done as an outpatient, and most often crutches are only used for a few days. Patient's do not need a bursa, and therefore there are few complications from this type of surgery. The most common complications are anesthetic-related complications, and infection. 4. ILIOTIBIAL BAND SYNDROME WHAT IS THE ILIOTIBIAL BAND? Iliotibial band syndrome is due to inflammation of the iliotibial band, a thick band of fibrous tissue that runs down the outside of the leg. The iliotibial band begins at the hip and extends to Page 7 of 10
the outer side of the shin bone (tibia) just below the knee joint. The band functions in coordination with several of the thigh muscles to provide stability to the outside of the knee joint. WHAT IS ILIOTIBIAL BAND SYNDROME? Iliotibial band syndrome (ITBS) occurs when there is irritation to this band of fibrous tissue. The irritation usually occurs over the outside of the knee joint, at the lateral epicondyle--the end of the femur (thigh) bone. The iliotibial band crosses bone and muscle at this point; between these structures is a bursa which should facilitate a smooth gliding motion. However, when inflamed, the iliotibial band does not glide easily, and pain associated with movement is the result. WHAT ARE THE SYMPTOMS OF ILIOTIBIAL BAND SYNDROME? As stated previously, the function of the iliotibial band is both to provide stability to the knee and to assist in flexion of the knee joint. When irritated, movement of the knee joint becomes painful. WHY DID I GET ILIOTIBIAL BAND SYNDROME? People who suddenly increase their level of activity, such as runners who increase their mileage, often develop iliotibial band syndrome. Others who are prone to ITBS include individuals with mechanical problems of their gait such as people who overpronate, have leg length discrepancies, or are bow-legged. WHAT IS THE TREATMENT FOR ILIOTIBIAL BAND SYNDROME? Treatment of ITBS begins with proper footwear, icing the area of pain, and a stretching routine. Limiting excessive training, resting for a period of time, and incorporating lowimpact crosstraining activities may also help. Anti-inflammatory medications may be prescribed by your doctor to help decrease the inflammatory response around the area of irritation. If these treatments do not solve the problem, working with a physiotherapist to develop a more focused stretching and strengthening routine may help. Cortisone injection into the area of inflammation may also be attempted, usually after these other treatments fail. If all else fails, surgery is an option, but only in very rare circumstances. The pain worsens with continued movement, and resolves with rest. 5. SNAPPING HIP SYNDROME WHAT IS SNAPPING HIP SYNDROME? Page 8 of 10
Snapping hip syndrome is a condition that is characterized by a snapping sensation, and often an audible 'popping' noise, when the hip is flexed and extended. There are several causes for snapping hip syndrome, most commonly due to tendons catching on bony prominences and "snapping" when the hip is moved. WHAT CAUSES SNAPPING HIP SYNDROME? There are three primary causes for snapping hip syndrome: Iliotibial Band Snap The iliotibial band is a thick, wide tendon over the outside of the hip joint. The most common cause of snapping hip syndrome is when the Iliotibial band (or "IT band") snaps over the greater trochanter (the bony prominence over the outside of the hip joint). If this is the cause of snapping hip syndrome, patients may develop trochanteric bursitis from the irritation of the bursa in this region. Iliopsoas Tendon Snap The iliopsoas tendon is the primary hip flexor muscle, and the tendon of this muscle passes just in front of the hip joint. The iliopsoas tendon can catch on a bony prominence of the pelvis and cause a snap when the hip is flexed. Usually when the iliopsoas tendon is the cause of snapping hip syndrome, patients have no problems, but may find the snapping annoying. Hip Labral Tear The least common cause of snapping hip syndrome is a tear of the cartilage within the hip joint. If there is a loose flap of cartilage catching within the joint, this may cause a snapping sensation when the hip is moved. This cause of snapping hip syndrome typically causes a snapping sensation, but rarely an audible "pop." This cause of snapping hip syndrome may also cause an unsteady feeling, and patients may grab for support when the hip snaps. ARE ANY TESTS NECESSARY TO DIAGNOSE SNAPPING HIP SYNDROME? An X-Ray is usually taken to confirm that there is no bony problem around the hip joint, but X- Rays are almost always normal with snapping hip syndrome. If the cause of snapping hip syndrome is thought to be due to a tear of the cartilage within the hip joint, an MRI may be obtained to look for evidence of this difficult to diagnose problem. IS ANY TREATMENT NEEDED FOR SNAPPING HIP SYNDROME? Page 9 of 10
Usually, simple reassurance that nothing serious is wrong is sufficient. A short course of antiinflammatory medications, or possibly a cortisone injection will help control inflammation if this is contributing to the problem. Physical therapy may be useful for stretching out the muscles and tendons that cause a snapping hip and may help prevent the problem. Surgery is rarely necessary and reserved for patients who have severe symptoms for long periods of time with adequate trial of non-operative treatments. If this is the case, surgery to relax the tendons, or remove the cartilage tear may help with the symptoms of a snapping hip. Page 10 of 10