Posterior Hip Pain: Hamstrings and Beyond Benjamin G. Domb, M.D. - - PowerPoint PPT Presentation

▶

Mar 31, 2024 427 likes •701 views

Posterior Hip Pain: Hamstrings and Beyond Benjamin G. Domb, M.D. Medical Director, American Hip Institute Director of Orthopedic Surgery Adventist Hinsdale Hospital Thanks to John Redmond, M.D., AHI Comprehensive Hip Fellow Hinsdale

SLIDE 1

Hinsdale Orthopaedics

Posterior Hip Pain:

Hamstrings and Beyond

Benjamin G. Domb, M.D.

Medical Director, American Hip Institute Director of Orthopedic Surgery Adventist Hinsdale Hospital

Thanks to John Redmond, M.D., AHI Comprehensive Hip Fellow

SLIDE 2

Hinsdale Orthopaedics

Posterior Hip Pain

SLIDE 3

Hinsdale Orthopaedics

Differential Diagnosis

Intra-articular

FAI
Dysplasia
Instability
DJD
AVN
Ligamentum

Teres

Labral Tear

Extra-articular

Piriformis
Hamstring
Ischiofemoral

Impingement

Troch Bursa
Gluteus Medius
Stress Fx
Sciatic Nerve

Spine

SI Joint
Spondylosis
Radiculopathy

SLIDE 4

Hinsdale Orthopaedics

Is it the Hip or Back?

History
Exam
Injections
Imaging

SLIDE 5

Hinsdale Orthopaedics

Diagnostic Algorithm

Redmond, Domb, et al, Arthroscopy 2014

SLIDE 6

Hinsdale Orthopaedics

Common Things are Common

Labral tears
38% present with buttock pain
FAI
29% present with buttock pain
DJD
Lumbar radiculopathy

Burnett, R.S., et al., Clinical presentation of patients with tears of the acetabular labrum. J Bone Joint Surg Am, 2006. 88(7): p. 1448-57. Clohisy, J.C., et al., Clinical presentation of patients with symptomatic anterior hip impingement. Clin Orthop Relat Res, 2009. 467(3): p. 638-44.

SLIDE 7

Hinsdale Orthopaedics

Extra-Articular Posterior Hip Problems

Piriformis Syndrome
Proximal Hamstring Pathology
Sciatic Nerve Entrapment
Ischiofemoral Impingement

SLIDE 8

Hinsdale Orthopaedics

Piriformis Syndrome

Definition: compression
f the sciatic nerve by

the piriformis muscle

Literature: primarily

case series and reviews

Eur Spine J (2010) 19:2095–2109

SLIDE 9

Hinsdale Orthopaedics

Piriformis Syndrome

Clinical Features –Systematic Review of

Symptoms from 51 articles - Eur Spine J (2010) 19:2095–2109

Buttock Pain in 50-95%
Low Back Pain in 14-63%
Aggravation of sciatica by sitting in 39-97%

SLIDE 10

Hinsdale Orthopaedics

Piriformis Syndrome

Physical Exam Tests for Piriformis Syndrome

SLIDE 11

Hinsdale Orthopaedics

Piriformis Syndrome

Objective evidence…..lacking
Fishman et al. attempted

nerve conduction studies with the hip in the FAIR position

Found a delay in the H reflex

in patients with suspected piriformis syndrome compared to controls

SLIDE 12

Hinsdale Orthopaedics

Piriformis Syndrome

Treatment
NSAIDs
Physical Therapy
Coriticosteroid Injection
Botox Injection
Surgical Release

SLIDE 13

Hinsdale Orthopaedics

Proximal Hamstring

Acute Injuries –

Avulsions

Biceps Femoris and

Semitendinosus

Chronic

Tendonopathy

Semimembranosus
Cohen. JAAOS 2007

SLIDE 14

Hinsdale Orthopaedics

Treatment Algorithm

Proximal Hamstring Injury MRI

Grade I <2cm >2cm Grade II Grade III Complete tear of 2 muscles or Grade IV&V

Conservative Surgery

Surgery

SLIDE 15

Hinsdale Orthopaedics

Endoscopic Repair of Proximal Hamstring Avulsion

Benjamin G Domb, MD; Dror Lindner, M.D.; Kinzie G Sharp, MS, PA-C; Adam Sadik, BS; Michael B Gerhardt, MD

SLIDE 16

Hinsdale Orthopaedics

Endoscopic Transtendinous Repair for Partial-thickness Proximal Hamstring Tendon Tears

Timothy J. Jackson, M.D., Anthony Trenga, B.A. Dror Lindner, M.D, M.D.,a Youseff El- Bitar,M.D.,a and Benjamin G Domb, MD

SLIDE 17

Hinsdale Orthopaedics

Sciatic Nerve Entrapment

The sciatic nerve can become entrapped

anywhere along its course

Fibrous or muscular entrapment
Vascular compression
Tumors
Scarring from trauma – hamstring rupture

SLIDE 18

Hinsdale Orthopaedics

Sciatic Nerve Entrapment

Symptoms
Buttock Pain
Radicular pain into the foot
Pain with sitting
Paresthesias

SLIDE 19

Hinsdale Orthopaedics

Sciatic Nerve Entrapment

Exam
Active piriformis test positive in

18 of 23 patients (78%)

Seated piriformis stretch 12 of 23

patients (52%)

Straight Leg Raise 4 of 23

patients(17%)

Martin et al. KSSTA. 2014

SLIDE 20

Hinsdale Orthopaedics

Sciatic Nerve Entrapment

Treatment
Variable – depending on the site of pathology
Sciatic Neurolysis
Martin et al. Arthroscopy 2010
35 patients treated with arthroscopic neurolysis
mHHS at avg 12 months 54 to 78
83% of patients had resolution of buttock pain

SLIDE 21

Hinsdale Orthopaedics

Ischiofemoral Impingment

Definition:

Abnormal contact between the lesser trochanter and the ischium

SLIDE 22

Hinsdale Orthopaedics

Ischiofemoral Impingement

Symptoms:
Groin pain
Buttock pain
Typically slow onset
Clunking during gait
Physical Exam:
Painful hip external

rotation in extension

Tenderness along the

posterior trochanter Safran et al. KSSTA. 2014

SLIDE 23

Hinsdale Orthopaedics

Ischiofemoral Impingement

MRI
Decreased space between the

ischium and lesser trocanter

Edema in the quadratus

femoris

Torrani et al. – Patients with

quadratus edema compared to controls – 13 vs 23 mm. (AJR 2009)

SLIDE 24

Hinsdale Orthopaedics

Ischiofemoral Impingement

Treatment
NSAIDs
PT
Surgical
Lesser trochanter

excision

Safran et al. KSSTA. 2014

SLIDE 25

Hinsdale Orthopaedics

Summary

Many causes of posterior hip pain
Use diagnostic algorithm
Intra- and extra-articular causes have

surgical treatment options

SLIDE 26

Hinsdale Orthopaedics

Thank You

www.AmericanHipInstitute.org

Benjamin G. Domb, M.D.

Medical Director, American Hip Institute Director of Orthopedic Surgery Adventist Hinsdale Hospital