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

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 Orthopaedics

Posterior Hip Pain Hinsdale Orthopaedics

Differential Diagnosis Intra-articular Extra-articular Spine • FAI • Piriformis • SI Joint • Dysplasia • Hamstring • Spondylosis • Instability • Ischiofemoral • Radiculopathy Impingement • DJD • Troch Bursa • AVN • Gluteus Medius • Ligamentum Teres • Stress Fx • Labral Tear • Sciatic Nerve Hinsdale Orthopaedics

Is it the Hip or Back? • History • Exam • Injections • Imaging Hinsdale Orthopaedics

Diagnostic Algorithm Hinsdale Redmond, Domb, et al, Arthroscopy 2014 Orthopaedics

Common Things are Common • Labral tears o 38% present with buttock pain • FAI o 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. Hinsdale Orthopaedics

Extra-Articular Posterior Hip Problems • Piriformis Syndrome • Proximal Hamstring Pathology • Sciatic Nerve Entrapment • Ischiofemoral Impingement Hinsdale Orthopaedics

Piriformis Syndrome • Definition: compression of the sciatic nerve by the piriformis muscle • Literature: primarily Eur Spine J (2010) 19:2095–2109 case series and reviews Hinsdale Orthopaedics

Piriformis Syndrome • Clinical Features –Systematic Review of Symptoms from 51 articles - Eur Spine J (2010) 19:2095–2109 o Buttock Pain in 50-95% o Low Back Pain in 14-63% o Aggravation of sciatica by sitting in 39-97% Hinsdale Orthopaedics

Piriformis Syndrome Physical Exam Tests for Piriformis Syndrome 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 Hinsdale Orthopaedics

Piriformis Syndrome • Treatment o NSAIDs o Physical Therapy o Coriticosteroid Injection o Botox Injection o Surgical Release Hinsdale Orthopaedics

Proximal Hamstring • Acute Injuries – Avulsions o Biceps Femoris and Semitendinosus • Chronic Tendonopathy o Semimembranosus Cohen. JAAOS 2007 Hinsdale Orthopaedics

Treatment Algorithm Proximal Hamstring Injury MRI Complete tear of 2 Grade III Grade II Grade I muscles or Grade IV&V <2cm >2cm Surgery Conservative Surgery 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 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 Hinsdale Orthopaedics

Sciatic Nerve Entrapment • The sciatic nerve can become entrapped anywhere along its course o Fibrous or muscular entrapment o Vascular compression o Tumors o Scarring from trauma – hamstring rupture Hinsdale Orthopaedics

Sciatic Nerve Entrapment • Symptoms o Buttock Pain o Radicular pain into the foot o Pain with sitting o Paresthesias Hinsdale Orthopaedics

Sciatic Nerve Entrapment • Exam o Active piriformis test positive in 18 of 23 patients (78%) o Seated piriformis stretch 12 of 23 patients (52%) o Straight Leg Raise 4 of 23 patients(17%) Martin et al. KSSTA. 2014 Hinsdale Orthopaedics

Sciatic Nerve Entrapment • Treatment o Variable – depending on the site of pathology o Sciatic Neurolysis o 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 Hinsdale Orthopaedics

Ischiofemoral Impingment • Definition: Abnormal contact between the lesser trochanter and the ischium Hinsdale Orthopaedics

Ischiofemoral Impingement • Symptoms: • Physical Exam: o Groin pain o Painful hip external rotation in extension o Buttock pain o Tenderness along the o Typically slow onset posterior trochanter o Clunking during gait Safran et al. KSSTA. 2014 Hinsdale Orthopaedics

Ischiofemoral Impingement • MRI o Decreased space between the ischium and lesser trocanter o Edema in the quadratus femoris o Torrani et al. – Patients with quadratus edema compared to controls – 13 vs 23 mm. (AJR 2009) Hinsdale Orthopaedics

Ischiofemoral Impingement • Treatment o NSAIDs o PT o Surgical  Lesser trochanter excision Safran et al. KSSTA. 2014 Hinsdale Orthopaedics

Summary • Many causes of posterior hip pain • Use diagnostic algorithm • Intra- and extra-articular causes have surgical treatment options Hinsdale Orthopaedics

Thank You www.AmericanHipInstitute.org Benjamin G. Domb, M.D. Medical Director, American Hip Institute Director of Orthopedic Surgery Adventist Hinsdale Hospital Hinsdale Orthopaedics