Hip pathology

What are the etiological factors of Femoroacetabular Impingement Syndrome (FAIS)?

Abnormal bone morphology

Cam deformity - bony prominence at the junction of femoral head and neck

Pincer lesion - bony overhang of the anterolateral acetabular rim

Mixed morphology - both

Genetic factors

Athletic activities and mechanical overload

What are the key pathophysiological findings in FAIS?

Pinching of labrum and cartilage

Cam deformity - shearing of the cartilage from subchondral bone

Pincer lesion - compressing and deforming the labrum

Mixed - Cam and pincer

Acetabular subchondral BMD is elevated in Cam

What are the most common signs and symptoms of FAIS on clinical presentation?

Gradual onset of hip pain, groin area, patient may describe C sign

Pain worsen hip flexion and IR

Anterior pinching pain with sitting, clicking, popping, catching, buckling, stiffness, and “giving way”

Dec hip flexion, IR

Faber and Anterior impingement sign, Trendelenburg gait (maybe)

What are the key mechanisms of injury for FAIS?

Abnormal contact between femoral head-neck junction and acetabular rim

Hx of slipped capital femoral epiphysis (SCFE)

Distinct traumatic event, repetitive microtrauma

What key anatomical structures are affected in FAIS?

Femoral head-neck junction, acetabular rim/acetabulum, acetabular labrum, articular cartilage, joint capsule

What else should be medically screened for that may contribute to FAIS?

Underlying hip conditions: SCFE, LCP, hip dysplasia

Referred pain - lumbar or sacroiliac

Other local hip pathologies

Rule out red flags

FAI Test cluster

FADIR - groin pain

FABER - pain groin/buttock, limited ROM

Hip scour - pain, apprehension

Resisted SLR - pain at hip joint

ROM IR at 90 hip flexion - <20 deg IR may indicate CAM

What medical imaging is recommended for FAIS?

X-rays AP pelvis and hip, Lateral hip - identify morphology

MRI - labral tear

What are the etiological factors of Legg-Calvé-Perthes disease (LCPD)?

Idiopathic, Mechanical overload and physical activity

Obesity

Metabolic, Biochemical, genetic, environmental Factors

What are the key pathophysiological findings in LCPD?

Interruption of vascular supply to femoral head, leading to avascular necrosis

Results in deformed femoral head

Leads to loss of shape, degenerative arthritis

What are the most common signs and symptoms of LCPD on clinical presentation?

Limping gait, antalgic gait, trendelenburg gait

Pain localized in hip, potentially isolated knee pain

Restricted hip abduction, internal rotation

Leg length discrepancy

What are the key mechanisms of injury for LCPD?

Idiopathic, trauma, steroid use

Combination of environmental, metabolic, genetic factors

Disruption of blood supply femoral head

What key anatomical structures are affected in LCPD?

Femoral head, hip joint, epiphysis, proximal femur, articular cartilage

What else should be medically screened for that may contribute to LCPD?

Obesity, referred pain, Genetic factors

What is the test cluster for LCPD

ROM - limited abd and IR

Trednelenburg - drop on contralateral side during stance

Antalgic gait

Palpation - pain in hip capsulle

Leg Roll - restricted or painful IR/ER

Leg length - shortening on affected side

What medical imaging is recommended for LCPD?

X-ray AP and frog leg, MRI - best method

What are the etiological factors of Developmental Dysplasia of the Hip (DDH)?

Genetic, environmental, mechanical, female sex

What are the key pathophysiological findings in DDH?

Abnormal acetabulum

Persistent subluxation or dislocation

What are the most common signs and symptoms of DDH on clinical presentation?

Limping gait, asymmetrical, trendelenburg gait

Hip Abduction <75, add > 30

Leg length descrepancies

Early OA

Positive Ortolani test and Barlow test

What are the key mechanisms of injury for DDH?

Abnormal hip development

interference of femur and acetabulum during development

Breech position

What key anatomical structures are affected in DDH?

Hip joint, acetabulum, femoral head, acetabular labrum

What else should be medically screened for that may contribute to DDH?

Family History, associated deformities, genetic factors, overloading

What is the test cluster for DDH

Barlow test - Hip dislocates with posterior pressure

Ortolani test - palpable clunk as femoral head reduces

Geleazzi Sign - one knee appears lower than other when hip and knees are flexed

Hip abduction - limited on affected side

What medical imaging is recommended for DDH?

Ultrasound, X-rays after 4-6 months of age, MRI

What are the etiological factors for Slipped Capital Femoral Epiphysis (SCFE)?

Weakness Physeal Plate, weak physis

Obesity (more weight and force transmitted through joint)

Genetic factors

What are the key pathophysiological findings in SCFE?

Abnormal displacement of the femoral epiphysis inferiorly and posteriorly relative to femoral neck and head

What are the most common signs and symptoms of SCFE on clinical presentation?

atraumatic hip, thigh, or knee pain

Limping or inability to bear weight

May be present for 4-5 months prior to diagnosis

Dec hip IR

What are the key mechanisms of injury for SCFE?

Mechanical shear forces across the physis

Periods of rapid growth

Pre-existing anatomical factors

What key anatomical structures are affected in SCFE?

Capital femoral epiphysis, femoral physis, femoral head and neck, metaphysis, acetabulum

What else should be medically screened for that may contribute to SCFE?

Endocrine and renal disorders

other traumatic injuries

Inflammatory: osgood-schlatter’s

What is the test cluster for SCFE

ROM - limited IR, abduction, flexion

Antalgic/trendelenburg gait

Drehmann Sign - involuntary external rotation during passive hip flexion

What medical imaging is recommended for SCFE?

X-rays - gold standard AP and frog-leg lateral

What are the etiology factors for Apophysitis and Apophyseal Avulsion Injuries?

Skeletal age - open around age 9 up

Mechanical overload and stress

Inflammation of the apophysis

What are the key pathophysiological findings in Apophysitis and Apophyseal Avulsion Injuries?

Inflammation at the apophysis

Avulsion fracture at attachment point of muscles

What are the most common signs and symptoms of Apophysitis and Apophyseal Avulsion Injuries on clinical presentation?

May feel pop at time of injury

Improved with rest, exacerbated by activity

Swelling, ecchymosis, TOP over bony prominences

Pain and weakness w/ resisted hip flexion

Gradual onset of symptoms

What are the key mechanisms of injury for Apophysitis and Apophyseal Avulsion Injuries?

Sudden, forceful eccentric muscle contractions

Athletic activity involving running, kicking, jumping

What key anatomical structures are affected in Apophysitis and Apophyseal Avulsion Injuries?

Secondary apophyses of hip and pelvis, AIIS, ASIS, Ischial tuberosity

Attached muscles and tendons

What else should be medically screened for that may contribute to Apophysitis and Apophyseal Avulsion Injuries?

Age and skeletal maturity

Muscle strain

What is the test cluster for apophysitis and apophyseal avulsion injuries

Palpation - localized tenderness at growth plate

MMT - pain w/ MMT of attached muscle group

Functional movements - pain w/ running, kicking, squatting

Mild antalgic gait, avoids terminal hip extension/flexion

What medical imaging is recommended for Apophysitis and Apophyseal Avulsion Injuries?

X-ray confirms diagnosis

MRI for intra-articular pathologies, muscle tears

What are the etiological factors of Labral and Acetabular Chondral Tears or Lesions?

Abnormal bony morphology/FAI

Mechanical overload

Dysplasia (DDH)

Shallow acetabulum, hypermobility

Trauma

Capsular Laxity

What are the key pathophysiological findings in Labral and Acetabular Chondral Tears/Lesions?

Labral tears: defunction, leading to microinstability, losing hip fluid seal

Chondral lesion

What are the key mechanisms of injury for Labral and Acetabular Chondral Tears/Lesions?

Abnormal Bony Morphology, hip dysplasia

Capsular laxity

Trauma

Degeneration - joint disease and aging

What key anatomical structures are affected in Labral and Acetabular Chondral Tears/Lesions?

Acetabular labrum, articular cartilage, Femoracetabular articulation, femoral head and neck, Joint capsule

What else should be medically screened for that may contribute to Labral and Acetabular Chondral Tears/Lesions?

Bony abnormalities, childhood hip conditions (DDH, LCP, SCFE)

Degenerative joint disease

Referred pain

What is the test cluster for labral and acetabular chondral tears or lesions

Audible/palpable clicking or catching

FADIR - pain

FABER - pain

Scour - pain

SLS - pain/pelvic drop <30s

Resisted SLR - groin pain

What medical imaging is recommended for Labral and Acetabular Chondral Tears/Lesions?

MRI, X-ray, Ultrasound

What are the etiological factors for Osteoarthritis (OA)?

Person level risk factors, Joint level risk, FAI/abnormal bony morphology, DDH

What are the etiological factors for Rheumatoid Arthritis (RA)?

Genetic, environmental factors, Infections and microbiome, autoantibodies

What are the key pathophysiological findings in OA?

Degeneration of articular cartilage and subchondral bone changes

Cartilage wear, tearing the labrum, chronic reptitive trauma

What are the key pathophysiological findings in RA?

Joint inflammation, usually starting in the fingers

Leads to destruction of joint, significant loss of catilage, bone erosions

What are the most common signs and symptoms of OA on clinical presentation?

Pain, aching, stiffness

Morning stiffness, groin poin, lateral hip pain

C sign, difficulty putting shoes and socks on

Significant ROM limitations in hip, especially IR and flexion

What are the most common signs and symptoms of RA on clinical presentation?

Inflammation of small joints then progresses to larger proximal joints

What are the key mechanisms of injury for OA?

Degenerative changes associated with aging

abnormal joint mechanics, resulting from FAI, DDH, SCFE, LCP

Genetic factors, occupational differences, BMI

Previous injuries (ACL)

What are the key mechanisms of injury for RA?

Autoimmune disease

Genetics

What key anatomical structures are affected in OA?

Articular Cartilage

Subchondral bone

Joint Space

Labrum

Femoral head and acetabulum

What key anatomical structures are affected in RA?

Synovial joints

Cartilage

Bone erosions

What else should be medically screened for that may contribute to OA?

Underlying hip deformities, Age, gender (female), High BMI, Genetics, trauma, Occupation

GTPS

What is the test cluster for OA

ROM - IR < 15, Flexion < 115

Morning stiffness up to 30 mins

Pain worsens with movement

What else should be medically screened for that may contribute to RA?

Comorbid conditions

Environmental factors

What medical imaging is recommended for OA?

X-ray - joint space, subchondral changes, osteophyte

MRI - cartilage

What medical imaging is recommended for RA?

No scan needed

What are the etiological factors for a Soft Tissue Contusion?

Blunt force trauma

What are the key pathophysiological findings in Soft Tissue Contusion?

Intramuscular hematoma

May involve: tendinous avulsion or partial/complete muscle tear

Complications: myositis ossificans, compartment syndrome

What are the most common signs and symptoms of Soft Tissue Contusion on clinical presentation?

HPCx blunt direct trauma

Visual findings: Bruises, cuts, bloodstains, swelling

Pain, antalgic limp, difficulty weight bearing

What are the key mechanisms of injury for Soft Tissue Contusion?

Blunt direct trauma

Muscle strains and tears from indirect trauma

What key anatomical structures are affected in Soft Tissue Contusion?

The muscles, tendons, bursae, blood vessels

What else should be medically screened for that may contribute to Soft Tissue Contusion?

Complications: comaprtment syndrome, myositis ossificans

Concomitant injuries: associated bony injuries, avulsion/fractures

Neurovascular below injury

Referred pain

What medical imaging is recommended for Soft Tissue Contusion?

X-rays - ruling out bony pathologies

MRI, US - muscle injury

What are the etiological factors of Greater Trochanteric Pain Syndrome (GTPS)?

Mechanical stress and overload, repetitive hip flexion and abduction, sustained or excessive hip adduction

Obesity, females, age (40-60), Postmenopausal,

Muscle weakness (glutes) or biomechanical imbalances

What are the key pathophysiological findings in GTPS?

Inflammation of peritrochanteric bursae

Abductor muscle tears, gluteal tendinopathy, thickening of ITB

Weak hip abductor muscles

Lower femoral neck-shaft angles

What are the most common signs and symptoms of GTPS on clinical presentation?

Localized lateral hip pain over greater trochanter, can radiate down lateral thigh

Agg by weight bearing, side bending, lying on affected side

TOP greater trochanter, pain and weakness with resisted hip abduction

Positive trendelenburg gait/stance and single leg stance (pain <30s), Faber test, Ober’s (ITB/TFL tightness)

What are the key mechanisms of injury for GTPS?

Overuse: Repetitive microtrauma and mechanical overload

Hip abductor dysfunction - weakness

Biomechanical factors - ITB, imbalances, bony morphology, excessive hip adduction

Concurrent conditions: FAI, bursitis,

Direct trauma - onto gluteal tuberosity

What key anatomical structures are affected in GTPS?

Glute med and min tendons, trochanteric bursae, ITB, Greater trochanter, TFL and hip abductors

What else should be medically screened for that may contribute to GTPS?

Hip OA (Positive Faber indicates GTPS over OA)

FAI

Lumbar radiculopathy

Leg length discrepancies, diabetes, previous hip surgeries

What is the test cluster for GTPS

Palpation of greater trochanter - localized pain over region

SLS - pain < 30s

FABER - pain over lateral hip

Resisted ER in flexion - pain

Resisted abduction - pain on lateral hip

Ober’s - pain over GT/tightness

What medical imaging is recommended for GTPS?

X-ray - rule out otherpathologies

MRI - muscle tendon, fluid collection in bursae