Lecture 12: Hip Disorders

Diagnostic classification system

1. Diagnosis that can be made on the basis of the history and physical examination – sprains, strains

2. Diagnosis that tentatively can be made on the basis of the history and the physical examination, but further diagnostic imaging and laboratory studies are necessary to confirm the diagnosis osteoarthritis, rheumatoid arthritis, herniated disc

3. Red flag diagnosis – fracture, dislocation, osteonecrosis, infection

Hip disease or Lumbar disease

• Pain referred from the hip the buttock lateral hip and groin are common sites pain referred from the lumbar spine and sacroiliac joints

• Diagnosing practitioner should always rule out involvement on the lumbar spine

Soft Tissue Disorders First Considerations

• Conservative treatment

• Adaptation of soft tissue to higher demands

• Best repair

Greater Trochanteric Pain Syndrome

Term used to include several soft tissue disorders

Greater Trochanteric Pain Syndrome Types

1. Greater trochanteric bursitis

2. Gluteus medius syndrome

3. Gluteus medius and minimus tendinopathy

4. Gluteus medius and minimus tears or strain

Greater trochanteric bursitis

Three bursae are usually present in the region of the greater trochanter

Greater trochanteric bursitis Causes/Correlations

More common with arthritic conditions

• Fibromyalgia

• Leg length discrepancies

More common in females than males

Result from a fall onto a hard surface – athletes

Friction of IT band over the trochanter during repetitive flexion/extension - athletes

Greater trochanteric bursitis treatments

• Responds well to conservative treatment

  • Physical therapy

  • Medication

• Surgical

  • final approach

Gluteus medius

• Key muscle for hip joint function

• Critical for balancing the pelvis in the frontal plane during single limb support

  • 60 percent of gait

  • approx. 3 times the body weight through the hip

Gluteus medius Weakness

• Trendelenburg’s gait pattern

  • Lean away from injured gluteus Medius

• Compensated Trendelenburg’s gait pattern – stress on lower lumbar spine

  • Cane - on opposite side of injury

  • Lean away from injured gluteus Medius

Gluteus medius and minimus tears or strains - Common clinical presentation

• buttock pain

• lateral hip pain

• groin pain

Gluteus medius and minimus tears or strains - issues with tendon

• Tendinosis – degeneration of collagen - more common – chronic

• Tendonitis – acute injury

  • see swelling, anti-inflammatory help

    
    

Gluteus medius and minimus tears or strains - treatment

• Responds well to conservative treatment

  • PT

• Surgical treatment

  • Option when conservative treatment is not successfu

Proximal Iliotibial Band Syndrome (explaination and causes)

Proximal ITB tightness or contracture

Can be primary cause of GTB

Secondary effect of

• OA

• Labral tear

• Gluteal tendonitis

Proximal Iliotibial Band Syndrome Treatment

Conservative treatment involves

• stretching exercises

Hip Flexion Contracture

• Common with hip dysfunction

  • Protective guarding - positioning of the hip into flexion in response to pain

Hip Flexion Contracture Causes

1. Shortening of the iliopsoas muscle

2. Shortening of the rectus femoris muscle

3. Shortening of the TFL muscle

4. Contracture of the anterior hip capsule

Hip Flexion Contracture development

1. Response to OA

2. Injury to hip

3. Repetitive flexed posture

4. Repetitive movement habit

Hip Flexion Contracture results in

• Loading through the hip joint is shifted to the thinner region of the hyaline cartilage

• The pelvis is placed in an anterior tilt with lumbar lordosis

• Hip extensors are placed in a state of constant , low level muscle tension

Hip Flexion Contracture - treatment

• Identifying which of the muscles are contracted

• Educating the patient in stretching techniques

Osteoarthritis

• Hip is one of the more common sights of involvement

• Affects approximately 1.5% of the adult population in US

Osteoarthritis - Clinical presentation

• Moderate anterior or lateral hip pain with weight bearing

• Older than 50

  • Morning stiffness for less than an hour

  • Limited hip medial rotation and flexion by 15 degrees compared to non painful side

Osteoarthritis Primary vs Secondary

• Primary OA – occurs without some predisposing mechanical

  alignment factor

• Secondary OA is the end result of another disease process – 80%

Predisposing Factors to Secondary Osteoarthritis

1. Osteonecrosis

2. Legg Calve-Perthes disease

3. Developmental dysplasia of the hip

4. Congenital Coxa vera or Coxa valga

5. Hip fracture

Osteoarthritis treatment

• Pharmacological

• Physical therapy and occupational therapy

  • Maintaining function

  • Relieving the symptoms

  • Preventing deformity

  • Patient education on hip protection

• Surgical

Osteoarthritis treatment - Surgical

• Once the pain can not be tolerated – limiting walking

  • Delaying too long may not be wise if it is worsening cardiovascular health

• Total hip arthroplasty

  • Physical therapy once again becomes critical for the patient to return to more normal activities

• Orthotic treatment post surgical – Hip abduction orthosis

Osteonecrosis - Subtypes

• Can occur in any joint but the hip joint is the most common

Two general subtypes

1. traumatic osteonecrosis – hip fracture – dislocation

• Displaced femoral neck fractures are treated by surgically replacing the femoral head

• Hip reduction needs to be performed within 8 hours

2. Nontraumatic osteonecrosis

• Hip pain – abrupt onset and severe

• Decrease hip ROM

• Stiffness

3. Bilateral involvement – in 50 percent

Osteonecrosis - treatment

• Numerous surgical approaches are taken

• Early detection – improved outcomes

Proximal Femur Fracture Stats

• Common orthopedic injury

  • Worldwide in 2000 – estimated 1.6 million hip fractures

    • increases in the elderly population will increase this number

  • More than 300,000 hip fractures occur each year in the US

  • Approximately 90% of elderly hip fracture result from a simple low energy fall

Some of the Most Common Risk Factors for Falls

1. Age

2. Gender females > males

3. Race – increase incidence in Caucasians

4. Social living situation – increase incidence with institutionalization

5. Medical history: increased incidence with multiple co-morbidities

6. Fall risk: increase with poor balance

7. Strength and endurance

8. Medication

Proximal Femur Fracture

• Poor balance reactions, decrease strength, weaker bones

• Older individuals – tend to fall on the hip because of their slower speed

• Younger elders often fall forward onto an out-stretched arm resulting in forearm fractures

Proximal Femur Fracture Treatment

• Need to be treated surgically

  • Allow for pain control

  • Early mobilization – reduce risks associated with prolonged bed rest and immobilization

  • Type of fixation - depends on the age of the patient , location and degree of displacement of the fracture

Proximal Femur Fracture – displaced femoral neck

• In older patients usually requires an arthroplasty – blood supply

• In younger patient surgeons will typically attempt to do an urgent anatomic reduction to save the hip rather then perform a hip arthroplasty

• Greater displacement the higher risk of avascular necrosis of the femoral head

Management of Dislocations after Hip Arthroplasty

• Uncommon complication if correct protocols are followed

• Most dislocations are posterior – excessive flexion and internal rotation

• Anterior dislocations are less common – excessive extension and external rotation

Management of Dislocations after Hip Arthroplasty - risk factors

1. Cognitive and neuromuscular conditions

2. Alcohol abuse

3. Prior hip surgery

4. History of prior dislocation

5. Hip dysplasia

   1. socket too small compared to head

6. Inflammatory arthropathy

   1. long term inflammatory effects soft tissue healing

7. Inadequate capsule repair with a posterior approach

   1. Surgery

8. Malpositioned components

   1. Surgery

9. Low head-to-neck ratio

   1. picked wrong hardware

10. Polyethylene wear

11. Abductor muscle weakness

Use of a hip abduction orthosis after revision

• Has not been proven to be more beneficial than use of abduction

  pillow when in bed

• Use of an orthosis is surgeon dependent

• Need to educate patient not to work against the brace

Management of Dislocations after Hip Arthroplasty - Neurological Injury

• Rare

• Peroneal division of the sciatic nerve is most commonly involved nerve

  • Weakness of dorsiflexors and everters of the foot and ankle

• A lot of times get return

Management of Dislocations after Hip Arthroplasty - Leg length discrepancy

• can occur after the procedure

• Shoe lift

  • Internal less than 1/2in

  • External greater than 1/2in