I have no relevant disclosures. What’s Hip: Top 5 Hip Problems in Primary Care Alan Zhang MD Assistant Professor Sports Medicine and Hip Arthroscopy UCSF Department of Orthopaedic Surgery December, 2015 2 Top 5 (or 6) Pathologies Big 3- Questions to Ask � STAIRS � Chronicity- When did it happen? � S tress Fracture � Mechanism- How did you injure it? � T rochanteric Pathology � A rthritis � Location- Where is the pain? � I mpingement � R eferred pain � S napping hip 3 4 1 12/11/2015 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]
Chronicity Mechanism of Injury � Acute � Contact � Chronic � Non-contact • Overuse • Twisting • Repetitive • Squatting microtrauma • Flexion/extension • Degenerative • “Pop” • No specific injury 5 6 Location, Location, Location Anatomy � Buttock/posterior • Low back/sciatic nerve • Referred pain Intra-articular Anatomy � Lateral/thigh • Trochanteric pathology • Snapping hip � Anterior/groin • Arthritis • Impingement (FAI) • Stress fracture 7 8 2 12/11/2015 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]
S tress Fracture Stress Fracture (Proximal Femur) � Acute on chronic injury � Sports- Track and field � Age group 18-60 (more commonly >40 years old) most common � Pain in groin, anterior thigh, deep in joint, worse with � MRI or bone scan for weightbearing diagnosis � PE- painful hop test � Treatment � Females >males • Rest, counseling, � Female athletic triad protected weight bearing • Stress fracture � RTP: 3-4 months • amenorrhea • eating disorder 9 10 T rochanteric Pathologies Trochanteric Bursitis � Trochanteric bursitis � Chronic pain from inflamed trochanteric bursa � Gluteus tear � Pain over lateral hip � Pain with direct palpation of greater trochanter � All have lateral sided hip pain � More common in females age 40-70 � Treatment • PT, CSI • If refractory >3 months then endoscopic bursectomy is option 11 12 3 12/11/2015 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]
Gluteus Tears Physical Exam Hip Abduction Testing � Chronic trochanteric bursitis can cause gluteus medius and minimus tearing � Chronic but can be from acute fall � Females 50-70 � Lateral pain and WEAKNESS with abduction on exam � Tredelenburg sign � Treatment • PT, CSI • If no improvement then endoscopic gluteus repair is an option 13 14 A rthritis of the Hip Clinical Presentation � Osteoarthritis most common � Physical Exam • Chronic pain, no specific injury • Decreased range of motion • Pain in groin, anterior thigh, deep • Pain in groin, lateral and posterior • Age >55 • Crepitus with ROM � Rheumatoid Arthritis • Altered gait • Family history • Multiple joints involved • Age >35 15 16 4 12/11/2015 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]
Radiographic Findings Treatment � AP Pelvis � Conservative • Joint space • Physical Therapy narrowing ‒ Gluteal and core strengthening • Subchondral sclerosis • Cortisone injection • Osteophytes ‒ Ultrasound or fluoroscopic guidance � Operative treatment • Total hip arthroplasty ‒ Anterior, anterolateral, posterior approach 17 18 I mpingement FA I � Abnormal bony anatomy that forms during development � Femoroacetabular Impingement (FAI) • Intense sports during childhood may be associated • Can lead to intra-articular injury to labrum and cartilage � More commonly chronic injury (can • Can lead to early arthritis be acute) � Age group 15 to 55 years old � Pain- groin/anterior or C-shaped band over the hip � Worse with prolonged sitting 19 20 5 12/11/2015 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]
FAI Hip Labral Tear- can be acute event • Cam-Type- femoral head neck asphericity • Pincer Type- acetabulum overcoverage • Mixed Type- both Cam and Pincer 21 22 Physical Exam Xrays • Flexion, adduction, internal rotation of hip causes pain 23 24 6 12/11/2015 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]
Radiographic Measurements MRI- can show labral/cartilage injury Alpha angle and head-neck offset Lateral Center Edge Angle and Cross-over sign 25 26 FAI Acquired During Skeletal Maturation in Prevalence of FAI in Athletes Athletes � Football- 90% of players at NFL Combine (2009-2010) had � Agricola et al AJSM 2014 at least 1 sign of FAI on xrays • 63 pre-professional soccer players in � Hockey- 75% of Elite Youth Hockey players in Colorado Netherlands had Cam lesion on MRI • Baseline Xray at age 12 showed 2% with Cam � Soccer- 72% of male and 50% of female elite soccer • F/u xrays 2 years later showed 18% with Cam players (MLS, US national team) had radiographic FAI 27 28 7 12/11/2015 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]
FAI and Arthritis Treatment � Conservative treatment is 1 st line � Rest � PT- core strengthening, gluteal strengthening • For patients <50 years old with hip arthritis • 45% due to FAI, 45% hip dysplasia, 10% trauma/other 29 30 Surgical Treatment- Hip Arthroscopy Cam Decompression 31 32 8 12/11/2015 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]
Labral Repair Labral Repair 33 34 Incidence of Hip Arthroscopy Zhang et al 2015 Outcomes � Byrd et al 2011 � 200 athletes with 2 year follow up after hip arthroscopy � 90% returned to sport (95% pro, 85% collegiate) 36 37 9 12/11/2015 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]
Does FAI Surgery Prevent Arthritis? R eferred Pain � Quantitative MRI to assess for early cartilage injury in hip � Hip pain can be referred from the lumbar spine or the knee � NIH funded study at UCSF- actively recruiting patients � Can be acute (lumbar disk herniation) � Usually located posterior in buttock region and radiates down the leg � Age group- >40 38 39 S napping Hip Referred pain � External snapping hip (lateral) � Lumbar radiculopathy • Ask about radiating or shooting pain, numbness or tingling • More common • IT band catching on greater trochanter • Pain that shoots from the hip down past the knee is usually from the spine and not the hip • Dancers, runners, soccer players • Obtain L-spine films if needed � Internal snapping hip (groin) � Knee pain • Iliopsoas snaps over the lesser trochanter or AIIS • Femoral nerve can cause referred hip pain when source is from the knee (and vice versa) � Treatment • Check radiographic and knee exam if hip films and exam is • PT- Rest, stretching, foam roll normal • Rarely- surgery for endoscopic IT band or iliopsoas release 40 41 10 12/11/2015 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]
IT Band Syndrome Iliopsoas Snapping/tendinopathy � Chronic pain over lateral thigh/hip pain from overuse • Low pitched snap on � Age group 20-40 flexion to extension of hip � Can cause contracture/tightness- External snapping hip (Thomas test) � Common in runners and bikers • Tender on deep palpation of anterior groin � Treatment • Rest, icing, stretching, • Sore with hyperflexion of hip • PT, foam roll • Endoscopic IT band release � RTP: 2-4 weeks 42 43 STAIRS Thank you � S tress Fracture • Female athlete triad � Alan Zhang, MD � T rochanteric Pathology � alan.zhang@ucsf.edu • Bursitis, gluteus tear � A rthritis � 415-885-3832 • Osteoarthritis, rheumatoid � I mpingement • FAI, Labral tears � R eferred pain • Lumbar spine/knee � S napping hip • IT band, Iliopsoas 44 45 Pediatric Hip Injuries 12/11/2015 11 12/11/2015 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]
References 1. Kocher MS, Tucker R. Pediatric athlete hip disorders. Clin Sports Med. 2006 Apr;25(2):241-53, viii. 2. Jayakumar P, Ramachandran M, Youm T, Achan P. Arthroscopy of the hip for paediatric and adolescent disorders: current concepts. J Bone Joint Surg Br. 2012 Mar;94(3):290-6. doi: 10.1302/0301-620X.94B3.26957. 3. Kovacevic D, Mariscalco M, Goodwin RC. Injuries about the hip in the adolescent athlete. ports Med Arthrosc. 2011 Mar;19(1):64-74. doi: 10.1097/JSA.0b013e31820d5534. 4. Frank JS, Gambacorta PL, Eisner EA. Hip pathology in the adolescent athlete. J Am Acad Orthop Surg. 2013 Nov;21(11):665-74. doi: 10.5435/JAAOS-21-11-665. 5. Byrd JW. Femoroacetabular impingement in athletes: current concepts. Am J Sports Med. 2014 Mar;42(3):737-51. doi: 10.1177/0363546513499136. Epub 2013 Aug 27. 6. Draovitch P, Edelstein J, Kelly BT. The layer concept: utilization in determining the pain generators, pathology and how structure determines treatment. Curr Rev Musculoskelet Med. 2012 Mar;5(1):1-8. doi: 10.1007/s12178-011-9105-8. 7. Byrd JW, Jones KS. Arthroscopic management of femoroacetabular impingement in athletes. Am J Sports Med. 2011 Jul;39 Suppl:7S-13S. doi: 10.1177/0363546511404144. 46 Pediatric Hip Injuries 12/11/2015 12 12/11/2015 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]
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