Medical management - hip region

Osteoarthritis (hip) definition

• arthritis and inflammation associated with loss of acetabular and/or femoral cartilage

primary OA (hip)

joint degradation from aging

secondary OA (hip)

joint degradation from factors other than aging

• obesity, trauma, congenital disorders

Tonnis grading system - OA

Grade 0: no signs of arthritis

Grade 1: sclerosis, minimal joint narrowing

Grade 2: subchondral cysts, moderate sclerosis, moderate joint narrowing

Grade 3: advanced arthritis, bone on bone osteophytes

Osteoarthritis (hip) epidemiology

• wearing down of hyaline cartilage leads to inflammatory response

  • causes thickening and sclerosis of subchondral bone

  • development of bone spurs and osteophytes

• symptomatic in 3% of adults >55 years

• 70% of all 70 year olds have radiographic evidence

• AFAB > AMAB

osteoarthritis (hip) signs and symptoms

• pain in area of the groin, hip, buttock

• stiffness

• crepitus

• Gait impairments:

  • decreased stance phase on involved extremity

  • trendelenburg pattern

  • antalgic pattern

  • others

osteoarthritis (hip) medical management

• diagnostic imaging

  • radiographs

• Stages 1-2 - PT and NSAIDs = first line of intervention

• Stages 2-3 - surgical option when QoL if affected

  • THA

    • anterior and posterior approach

    • cemented or non-cemented prothesis

  • Hip hemi - arthroplasty

femoral acetabular impingement (FAI) definition

abnormal mechanical contact between rim of acetabulum and upper femur

CAM lesion (FAI)

aspherical epiphyseal extension that produces a characteristic bump at junction of femoral head and neck

Pincer lesion (FAI)

global over-coverage, focal over-coverage, and retroversion of the acetabulum

• results in premature contact between femoral neck and acetabular rim when hip is flexed

femoral acetabular impingement (FAI) etiology

• mechanisms of injury:

  • supra-physiologic flexion or rotational movements of the hip

  • repetition

  • forceful motions

• injury to:

  • acetabular labrum

  • cartilage around acetabular rim

femoral acetabular impingement (FAI) epidemiology

higher prevalence in asymptomatic individuals

femoral acetabular impingement (FAI) signs and symptoms

• pain characteristically located to groin

  • can be in buttock, lower back, trochanteric region, or anterior thigh and knee

• aggravating activities

  • athletic or functional activities requiring hip flexion (squatting, sitting)

• painful and limited AROM with hip flexion

• (+) FADIR test

• (+) resisted SLR test

• (+) posterior impingement test

femoral acetabular impingement (FAI) medical management

• diagnostic imaging

  • radiographs

  • MRI

• NSAIDs

• PT

• surgery

  • arthroscopy

    • femoroplasty

labral tear of the hip definition

A.K.A. acetabular rim syndrome or acetabular labral tear

• tear of the cartilage lining the acetabulum of the hip joint

labral tear of the hip etiology

• due to

  • traumatic process

  • repetitive micro-trauma

  • degenerative changes

• pain reported in anterior hip or groin in >90% of patients

• high occurrence in those with past hip pathologies of hip surgery

• most common in anterior or anterosuperior aspect of labrum

labral tear of the hip epidemiology

• AFAB > AMAB

• common in >60 year olds due to degenerative changes

• highly active 20-40 year olds

labral tear of the hip signs and symptoms

• reports of:

  • clicking (most common)

  • locking

  • catching

  • giving way

• aggravating factors

  • pivoting

  • twisting

• pain reported deep in anterior hip or groin

• gradual onset, symptoms present >2 years

labral tear of the hip medical management

• diagnostic imaging

• MR arthrogram

  • 66-95% sensitivity

  • 71-88% specificity

• NSAIDs prn

• PT

• surgery

  • arthroscopic debridement (gold standard - 91% successful in symptom relief)

  • open labral surgery

greater trochanteric pain syndrome definition

“the great mimicker”, formerly known as greater trochanteric bursitis

• pain and reproducible tenderness at the region of the greater trochanter, buttock, or lateral thigh

greater trochanteric pain syndrome: common associated pathologies

• tendinitis

• muscle tears

• trigger points

• iliotibial band disorders (ITB)

greater trochanteric pain syndrome etiology

• lateral hip structures subjected to repetitive micro-trauma or direct trauma from a fall or blow

• initial inflammatory reaction causing a bursitis or tendonitis

greater trochanteric pain syndrome epidemiology

• prevalence:

  • 10%-25% of the population

  • 20%-35% of adults with musculoskeletal LBP

  • most commonly affects 40-50 year old AFAB and individuals >60

greater trochanteric pain syndrome signs and symptoms

• pain intermittent to constant in the lateral hip region, may spread down to the lateral thigh and into the buttock

• pain increases with walking, running, sidelying on affected side

• pain with palpation

• immediate relief with cotisone injection to the appropriate structure

greater trochanteric pain syndrome medical management

• diagnostic imaging: used to rule out other pathologies (OA, AVN, fractures, labral tears)

• NSAIDs

• local cortisone injections

• behavior (sleeping position) and activity modifications

• PT - mindful of potential for affected structures to refer to other structures

neck or subcapital fracture

• greatest risk of AVN

• will require hemiarthroplasty if displacement is present

• will require ORIF if displacement is not present

pubic ramus stress fracture signs and symptoms

• inferior ramus is more common than superior ramus

• pain in groin, buttocks, or thigh

• tenderness to palpation at pubic symphysis

fractures of the hip region etiology/epidemiology

• traumatic, pathologic, or osteoporotic (usually femoral neck)

• 10-20% of patients require long term nursing care

• traumatic and osteoporotic more common in AFAB

fractures of the hip region signs and symptoms

• pain in deep hip region, groin, thigh, and buttocks

• usually worse while WB

• LE deformity with displaced fractures

  • changes in leg length

  • excessive resting rotation

• Antalgic Gait

slipped capital femoral epiphysis (SCFE) definition

displacement of the capital femoral epiphysis from the femoral neck through the epiphyseal plate

slipped capital femoral epiphysis (SCFE) epidemiology

• 10.8 cases per 100,000 children in US

• AMAB > AFAB

• between 10-16 years

• obesity reported in 75% of patients

slipped capital femoral epiphysis (SCFE) signs and symptoms

• insidious onset

• Gait abnormalities

• severe pain in hip, thigh, or knee

• decreased hip ROM

• inability to bear weight on affected extremity

slipped capital femoral epiphysis (SCFE) medical management

• diagnostic imaging

  • radiograph (gold standard)

• patients are strictly non weight bearing until surgery

  • ORIF with single screw

Legg Calve Perthes disease LCPD definition

• results from idiopathic osteonecrosis of the capital femoral epiphysis of the femoral head;

  • bone infarction in the subchondral bone while articular cartilage continues to grow

Legg Calve Perthes disease LCPD epidemiology

• 1 in 1200 children

• most commonly seen in AMAB caucasian children 1-12 years old

  • may be more likely in physically active children who are small for their age and exposed to second hand smoke

Legg Calve Perthes disease LCPD signs and symptoms

• limp with gait

• groin, hip, or knee pain

• increased pain with WB activity

• bilateral involvement in 10-13% patients

Legg Calve Perthes disease LCPD medical management

• diagnostic imaging

  • radiographs

• PT

• NSAIDs

• temporary bracing

• surgery

  • osteotomy

  • hemi-arthroplasty

Legg Calve Perthes disease LCPD prognosis

complete healing 3-5 years, 60-70% of patients heal without long term disability

avascular necrosis of the hip definition

destruction and death (ischemia) of the femoral head

avascular necrosis of the hip etiology

• numerous factors associated with the compromise of blood flow

  • femoral neck fracture, posterior hip dislocation, hip surgery, trauma, idiopathic

  • corticosteroid use, excessive alcohol intake, smoking, pregancy

  • lupus, gout, diabetes mellitus, sickle cell disease

• progressive, joint destruction usually within 3-5 years

  • but in some cases, only a few months

avascular necrosis of the hip epidemiology

• most commonly affects 40-50 year olds

• AMAB 8x > AFAB

• 2500-3300 new cases annually

avascular necrosis of the hip process

• decreased blood flow

• changes in subchondral bone

• initially, articular cartilage spared, no changes in joint space

• femoral head collapse

• joint space narrows

• cartilage damage ensues

avascular necrosis of the hip signs and symptoms

• pain felt deep in hip, buttock, thigh, and/or groin

• decreased pain in in non-WB positions

• complaints of stiffness

• limited hip motion in multiple directions that does not follow a capsular pattern

  • due to damage to the femur, NOT the capsule

avascular necrosis of the hip medical management

• diagnostic imaging

  • radiographs

  • MRI (more sensitive than x-ray)

• NSAIDs, analgesics

• PT (conservative and post surgical)

• surgery

  • core decompression

  • osteotomy

    • rotation of the femoral head

  • THA

Snapping hip syndrome definition

A.K.A iliopsoas syndrome or trochanteric syndrome

• characterized by an audoble or palpable snap or click, may or may not be painful

• 3 types - external, internal, interarticular

external snapping hip syndrome etiology

• most common form

• ITB, TFL, or anterior fibers of gluteus max sliding over greater trochanter

• friction results in irritation and inflammation

internal snapping hip syndrome etiology

• iliopsoas tendon flipping or snapping over femoral head, anterior capsule, ASIS, or lesser trochanter

interarticular snapping hip syndrome etiology

• clicking or catching that occurs due to labral tears or loose bodies within the joint capsule

Snapping hip syndrome epidemiology

• AFAB > AMAB

• Ages 15-40

• common in athletes (dancers, gymnasts, cyclists, runners)

Snapping hip syndrome signs and symptoms

• may or may not be painful

• can be describes as deep ache

• always associated with snapping or clicking

• intermittent symptoms with consistent pattern of movement

• generally local symptoms

  • increased inflammation can be associated with referred pain along lateral thigh

Snapping hip syndrome medical management

• PT

• NSAIDs prn

• diagnostic imaging with failed PT

piriformis syndrome definition

any condition of the piriformis causing local pain in the buttocks with or without referred symptoms into the lower extremity due to compression or irritation of the sciatic nerve

piriformis syndrome causes

• nerve entrapment at the piriformis

• piriformis strain

• myofascial pain from direct trauma to the muscle

• compression or irritation of the sciatic nerve from direct trauma to the nerve

piriformis syndrome epidemiology

• 15-20% of the population has sciatic nerve passing through piriformis muscle

• 6% of sciatica medical diagnosis due to piriformis syndrome

• AFAB > AMAB

types of fractures of the hip region

• neck or subcapital

• intertrochanteric

• subtrochanteric

• fractures of the:

  • greater trochanter

  • lesser trochanter

fractures of the hip that require ORIF

• neck or subcapital

• intertrochanteric

• subtrochanteric

fractures of the hip that do not require ORIF

• fractures of the greater trochanter

• fractures of the lesser trochanter

hip fractures requiring ORIF surgeries utilizing pins, nails, or screws

• subcapital fracture

• femoral neck fracture

hip fractures requiring ORIF surgeries utilizing compression/dynamic screw

• intertrochanteric fracture

• subtrochanteric fracture

how a compression/dynamic screw works

• prevents angular deformation

• allows fracture impaction for bone stimulation

• maintains 135 degree angle of femoral neck and head into socket

movement causing posterior hip dislocation

hip internal rotation with flexion and adduction

hip dysplasia definition

comprehensive term describing developmental hip problems in infants and children, often present at birth

movement causing anterior hip dislocation

hip external rotation with extension and abduction

risk factors for babies diagnosed hip dysplasia

• hip click

  • hip joint lacks development

• breech presentation

  • feet down within womb; first to exit womb

• family history of hip dysplasia

hip dysplasia medical management

• medical imaging

  • ultrasound <4 months

  • radiograph >4 months

• brace the femur/hip (frog position)

  • may require closed reduction

  • period of leg traction may be needed to facilitate the reduction

    • spica cast following reduction

    • hip abduction cast following spica cast

hip dysplasia prognosis

• when diagnosed within first 6 weeks of life, treatment with a harness is 90% successful

• after 1 year, multiple operations usually required and a normal hip may not develop