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Advances in Diagnosis and Treatment of Hip Injuries
Alan Zhang MD Assistant Professor Sports Medicine and Hip Arthroscopy UCSF Department of Orthopaedic Surgery
I have no relevant disclosures.
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Most Common Hip Pathologies
STAIRS Stress Fracture
Trochanteric Pathology
Arthritis Impingement
Referred pain
Snapping hip
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Big 3- Questions to Ask
Chronicity- When did it happen?
Mechanism- How did you injure it?
Location- Where is the pain?
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Chronicity
Acute Chronic
• Overuse
• Repetitive microtrauma
• Degenerative
• No specific injury
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Mechanism of Injury
Contact Non-contact
• Twisting
• Squatting
• Flexion/extension
• “Pop”
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Location, Location, Location Buttock/posterior
• Low back/sciatic nerve
• Referred pain
Lateral/thigh
• Trochanteric pathology
• Snapping hip
Anterior/groin
• Arthritis
• Impingement (FAI)
• Stress fracture
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Anatomy
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Intra-articular Anatomy
Stress Fracture
Acute on chronic injury (overtraining)
Age group 18-60 (more commonly >40 years old)
Pain in groin, anterior thigh, deep in joint, worse with weightbearing
PE- painful hop test
Females >males
Female athletic triad
• Stress fracture
• amenorrhea
• eating disorder
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Stress Fracture (Proximal Femur)
Sports- Track and field most common
MRI or bone scan for diagnosis
Treatment
• Rest, counseling, protected weight bearing
RTP: 3-4 months
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Trochanteric Pathologies
Trochanteric bursitis
Gluteus tear
All have lateral sided hip pain
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Trochanteric Bursitis
Chronic pain from inflamed trochanteric bursa
Pain over lateral hip
Pain with direct palpation of greater trochanter
More common in females age 40-70
Treatment
• PT, CSI
• If refractory >3 months then endoscopic bursectomy is option
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Gluteus Tears
Chronic trochanteric bursitis can cause gluteus medius and minimus tearing
Chronic but can be from acute fall
Females 50-70
Lateral pain and WEAKNESS with abduction on exam
Tredelenburg sign
Treatment
• PT, CSI
• If no improvement then endoscopic gluteus repair is an option
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Physical Exam
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Hip Abduction Testing
Arthritis of the Hip
Osteoarthritis most common
• Chronic pain, no specific injury
• Pain in groin, anterior thigh, deep
• Age >55
Rheumatoid Arthritis
• Family history
• Multiple joints involved
• Age >35
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Clinical Presentation
Physical Exam
• Decreased range of motion
• Pain in groin, lateral and posterior
• Crepitus with ROM
• Altered gait
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Radiographic Findings
AP Pelvis
• Joint space narrowing
• Subchondral sclerosis
• Osteophytes
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Treatment
Conservative
• Physical Therapy
‒ Gluteal and core strengthening
• Cortisone injection
‒ Ultrasound or fluoroscopic guidance
Operative treatment
• Total hip arthroplasty
‒ Anterior, anterolateral, posterior approach
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Impingement
Femoroacetabular Impingement (FAI) • Abnormal bony anatomy that forms during
development
Age group 15 to 45 years old
More commonly chronic injury (can be acute)
Can lead to intra-articular injury to labrum and cartilage
Can lead to early arthritis
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FAI
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• Cam-Type- femoral head neck asphericity • Pincer Type- acetabulum overcoverage • Mixed Type- both Cam and Pincer
Hip Labral Tear- can be acute event
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FAI- Common symptoms
Pain
• Anterior groin and in c-shaped band
• Worse with prolonged sitting
• Sit to stand
• Activity related (walking, running, jumping, squats)
• Pts may complain of hip tightness or inflexibility
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Physical Exam
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• Flexion, adduction, internal rotation of hip causes pain
Imaging
Radiographs (AP pelvis, Dunn Lateral)
MRI/MRA
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MRI- can show labral/cartilage injury
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Prevalence of FAI in Athletes
Football- 90% of players at NFL Combine (2009-2010) had at least 1 sign of FAI on xrays
Hockey- 75% of Elite Youth Hockey players in Colorado had Cam lesion on MRI
Soccer- 72% of male and 50% of female elite soccer players (MLS, US national team) had radiographic FAI
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FAI Acquired During Skeletal Maturation in Athletes
Agricola et al AJSM 2014 • 63 pre-professional
soccer players in Netherlands
• Baseline Xray at age 12 showed 2% with Cam
• F/u xrays 2 years later showed 18% with Cam
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FAI and Arthritis
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• For patients <50 years old with hip arthritis • 45% due to FAI, 45% hip dysplasia, 10% trauma/other
Treatment
Conservative treatment is 1st line
Rest
PT- core strengthening, gluteal strengthening
If fails PT then intra-articular CSI
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Intra-articular injection of anesthetic/steroid
Ultrasound or fluoroscopically guided intra-articular corticosteroid injections commonly used in US
Can help to localize an intra-articular source of hip pain
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CSI for Hip Pain
• Diagnostic modality for localization of source of pain
‒ 90% accuracy (Byrd et al 2004)
• Therapeutic effect
‒ Pain improvement variable duration (2 weeks to 2 months)
Surgical Treatment- Hip Arthroscopy
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Cam Decompression
Pre-op Post-op
Alan Zhang, MD UCSF Hip Arthroscopy
Pincer Decompression
6/1/17 34
Labral Repair
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Labral Repair
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20,484,172 unique orthopedic patients analyzed
8,227 hip arthroscopy cases
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Outcomes
Byrd et al 2011
200 athletes with 2 year follow up after hip arthroscopy
90% returned to sport (95% pro, 85% collegiate)
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Does FAI Surgery Prevent Arthritis? Quantitative MRI to assess for early cartilage injury in hip
NIH funded study at UCSF- actively recruiting patients
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Referred Pain
Hip pain can be referred from the lumbar spine or the knee
Can be acute (lumbar disk herniation)
Usually located posterior in buttock region and radiates down the leg
Age group- >40
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Referred pain
Lumbar radiculopathy
• Ask about radiating or shooting pain, numbness or tingling
• Pain that shoots from the hip down past the knee is usually from the spine and not the hip
• Obtain L-spine films if needed
Knee pain
• Femoral nerve can cause referred hip pain when source is from the knee (and vice versa)
• Check radiographic and knee exam if hip films and exam is normal
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Snapping Hip
External snapping hip (lateral) • More common
• IT band catching on greater trochanter
• Dancers, runners, soccer players
Internal snapping hip (groin) • Iliopsoas snaps over the lesser trochanter or AIIS
Treatment • PT- Rest, stretching, foam roll
• Rarely- surgery for endoscopic IT band or iliopsoas release
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IT Band Syndrome
Chronic pain over lateral thigh/hip pain from overuse
Age group 20-40
Can cause contracture/tightness- External snapping hip
Common in runners and bikers
Treatment
• Rest, icing, stretching,
• PT, foam roll
• Endoscopic IT band release
RTP: 2-4 weeks
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Iliopsoas Snapping/tendinopathy
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• Low pitched snap on flexion to extension of hip (Thomas test)
• Tender on deep palpation of anterior groin
• Sore with hyperflexion of
hip
Stress Fracture • Female athlete triad
Trochanteric Pathology • Bursitis, gluteus tear
Arthritis • Osteoarthritis, rheumatoid
Impingement • FAI, Labral tears
Referred pain • Lumbar spine/knee
Snapping hip • IT band, Iliopsoas
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STAIRS Thank you
Alan Zhang, MD
415-353-4843
6/1/17 46
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25(2):241-53, viii.
2. Jayakumar P, Ramachandran M, Youm T, Achan P. Arthroscopy of the hip for paediatric and adolescent disorders: current concepts. J Bone Joint Surg Br. 2012 Mar;94(3):290-6. doi: 10.1302/0301-620X.94B3.26957.
3. Kovacevic D, Mariscalco M, Goodwin RC. Injuries about the hip in the adolescent athlete. ports Med Arthrosc. 2011 Mar;19(1):64-74. doi: 10.1097/JSA.0b013e31820d5534.
4. Frank JS, Gambacorta PL, Eisner EA. Hip pathology in the adolescent athlete. J Am Acad Orthop Surg. 2013 Nov;21(11):665-74. doi: 10.5435/JAAOS-21-11-665.
5. Byrd JW. Femoroacetabular impingement in athletes: current concepts. Am J Sports Med. 2014 Mar;42(3):737-51. doi: 10.1177/0363546513499136. Epub 2013 Aug 27.
6. Draovitch P, Edelstein J, Kelly BT. The layer concept: utilization in determining the pain generators, pathology and how structure determines treatment. Curr Rev Musculoskelet Med. 2012 Mar;5(1):1-8. doi: 10.1007/s12178-011-9105-8.
7. Byrd JW, Jones KS. Arthroscopic management of femoroacetabular impingement in athletes. Am J Sports Med. 2011 Jul;39 Suppl:7S-13S. doi: 10.1177/0363546511404144.
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