Understanding the diagnosis of hip problems: When to refer to the surgeon and when to hold on! Dirk Kokmeyer, PT, DPT, SCS, COMT Director of Rehabilitation and Performance Maine Medical Partners, Orthopedics and Sports Medicine Portland, Maine dkokmeyer@mmc.org @DirkKokmeyer
Disclosures
The Patient • Physical demands • Satisfaction • Expectation Expertise/opinion • Pragmatism • Humility • Understanding The Evidence EBM clinical pathways • Success of PT • Indication for surgery • Surgical success
Formulating the hot vs. crazy matrix • HPI with Inventory of: - Red flags? - Pain - functional demands - physical demands (sport) • Clinical Exam • Prognosis - What I can do for you… - How long will it take? - How much satisfaction? • Treatment - success?
Surgeon Soft tissue disorders • Bursitis • Lat. trochanteric pain syndrome • Tendon -opathy/tears Patient Values Athletic Pubalgia Nerve Entrapment Clinical Expertise Hip Pain Evidence Hip Stiffness Patient Values Hip/LE Dysfunction Clinical Expertise FAI/Labral Tear Evidence Referred pain Chondral issues • Chondral Lesion • Lumbar Spine • OA • SIJ Physical Therapist • Other
Understanding the diagnosis/clinical pathway Surgeon Sports Sports Med PCP Perf/PT
Patient Expectation Dunn, JSES, 2016 NEER AWARD Mohamad, J of Rheumatology, 2002 Nicholas, PTJ, 2011 Puendetura, JOSPT, 2012
Irritability Classification High Moderate Low Moderate Pain (4-6/10) High Pain (≥7/10) Low Pain (≤3/10) Intermittent night or rest Consistent night or rest pain pain No resting or night pain High disability/low function Moderate disability/function Low disability/high function on WOMAC, HHS, HOS on WOMAC, HHS, HOS on WOMAC, HHS, HOS Pain prior to end ROM Pain at end ROM Minimal pain at end ROM with overpressure AROM less than PROM AROM similar to PROM secondary to pain AROM same as PROM PROM, modalities, pain Functional activities, PROM, modalities, pain reduction, activity strengthening as tolerated, reduction, activity modification activity modification modification Referral in 4-8 weeks if no Referral in 6-8 weeks if Referral sooner if no change change in symptoms surgical indications in symptoms Modified from: •Kelley, McClure and Leggin, JOSPT 2009 •McClure, Michener, PTJ, 2015
Red Flags • Cancer • Fractures • AVN • Legg-Calve-Perthes Disease • SCFE • Septic Arthritis • Inguinal Hernia • Appendicitis • Ovarian Cyst
Fractures Kirby et al, MSK Imaging, 2010: 14% of hip fractures missed by radiographs Dominguez, Acad Emerg Med, 2005: 4.4% hip fractures missed
Falls and fractures among the elderly • 1/5 falls cause serious injury (i.e. hip fracture) • 2x risk of falling after 1º fall • <50% tell MD about a fall • >300,000/year hospitalized for hip fractures • women > men • $31 billion/year
Range of motion demands of the hip • Hemmerich, 2006 • Hyodo, 2017 • Andriacchi, 1980 Stairs ~40º Squatting 90-140º Don + Tying shoes 85-90º IR ~10º Putting on pants ~86º IR 13-15º Getting in/out tub 79-99º IR 15-17º
Case example of gentleman referred with knee pain and hip OA
Altman et al, Arthritis and Rheumatism , 1991 HIP PAIN + Hip IR < 15º Hip Flex < 115º Morning Age >50 Stiffness yrs >60 min Sensitivity 86%, Specificity 75%
Altman et al, Arthritis and Rheumatism , 1991 HIP PAIN + Joint Space narrowing Femoral/ Acetabular Osteophytes Sensitivity 91%, Specificity 89%
Treatment options and efficacy Physical Therapy: Beumer et al, BJSM, 2016 SR with meta-analysis • Exercise therapy: good short-term benefit with pain/WOMAC • Manual Therapy: No additional benefit
Treatment options and efficacy Pisters et al, Ostoearthritis and Cartilage , 2010 • RCT of two exercise protocols with 60 month follow-up • Long-term: reduced pain, fewer TJAs, better WOMAC • Booster session a key element
Treatment options and efficacy Svege et al, Ann Rheum Dis , 2015 • 41% survival rate at 6 year f/u with exercise + education • symptom severity (lower WOMAC) in patients undergoing THR
Surgery Indications for Surgery (THA): Quintana, J of Clin Epidemiology , 2000 • Surgery inappropriate if: • mild pain > mild - mod limitations • mod-severe pain < 50 • mod-severe pain > 50, low limitations • Surgery uncertain if: • mild-mod pain - moderate limitations - low to high surgical risk - failed “correct” conservative mgmt • mild-moderate pain - severe functional limitation - failed conservative mgmt • High pain - low functional limitation
Surgery Indications for Surgery (THA): Gademan, BMC Musc Dis , 2016 • Failed conservative management WRT pain • Typically >50 • Severe pain • WOMAC >60
Hold on!
Athletic Pubalgia “sports hernia” c/c: severe groin, lower abdominal or pubic region, induced by exertion. Definition: weakness of the posterior inguinal wall. Involves injury to the (Meyer, ann of surg , 2008): • insertion of the distal R abdominus • conjoined tendon • external oblique aponeurosis • adductor tendon(s)
Diagnosis Cluster of findings: 1. Subjective complaint of deep groin, abdominal, pubic pain 2. Pain exacerbated with sport specific movements: running, kicking, cutting. 3.TTP: pubic symphysis, conjoined tendon, int/ext obliques, adductor insertions 4.Pain with resisted hip adduction and/or hip flexion 5.Pain with resisted curl-up
Athletic Pubalgia algorithm to treatment Kachingwe and Grech, JOSPT, 2008 Indication for PT based on: RTP> 4 mo & + hx of “rip” -hx of “rip” not high-performance athlete Surgery indicated if: + hx of “rip”, RTP< 4 mo - hx of “rip” & failed PT
“The Sports Hip Triad” • Feely, AJSM , 2008 } 1997-2006: 23,806 injuries } 738 hip injuries • Hammoud, Arthroscopy, 2012 - 38 pro athletes } 32% (12/38) had AP surgery also required FAI surgery } 39% (15/38) had complete resolution of AP symptoms with FAI surgery alone
FAI and Labral Pathology Burnett et al, JBJS, 2006 • 21 months to dx labral pathology • average of 3.3 providers seen before dx made
FAI and Labral Pathology Hx: • Clicking: 100% Sens, 79% Spec, +LR 6.67, r=0.79 for labral tears • Anterior groin pain. (Sens 96-100%) • Lateral and posterior pain possible • FAI: anterior pinching with sitting Special Tests: Thomas Test, FADDIR (and derivatives) = • High Sens, Low Spec Reiman et al, BJSM , 2013
SURVEY SAYS Surgeon 2: Surgeon 1: Surgeon 4: Surgeon 5: Skeletally immature Skeletally immature: Skeletally immature Skeletally immature: Female: Female: •If non-dysplastic, • If limping with knee or • PT. Emphasis on • Maximize PT benefit will treat more hip pain, refer quickly soft tissue • no bone work until aggressively with for imaging and MD Young male: growth plate closed surgery if + MRI eval (r/o SCFE). • short course of PT, • PT x 12 weeks • If imaging neg. PT OK but not afraid to fix a 18-30 big CAM lesion Young male: Skeletally mature: •Will treat more quickly. • Will scope quickly • 6 week course of PT. aggressively with Young female: with radiographic Referral OK if no surgery and see • PT with emphasis on evidence of FAI improvement noted. sooner if PT pelvic control + glute 40+ firing Young female: Surgeon 3: • “no rush” • No pain relief with • PT x 8 weeks • Will do a CSI if no “I don’t believe in injection = return to improvement paternalism; it’s up to PT >40 female • Will see earlier with the PT” >35 female • PT x 12 weeks increase tissue + Scour/FADIR, failed • Maximize therapeutic >40 male irritability conservative mgmt, pt is benefit! • Will take a referral miserable = refer! • Keep going if better! sooner
FAI and Labral Pathology • Schmitz, AJSM, 2012 (42 asymptomatic participants) • Paralabral cysts in 20% • Labral tears in 80-85% “We believe that it is beneficial and essential to consider other sources of pain besides the labrum itself”
Labral tear 69% Chondral defect 24% Ligamentum teres tear 2.2% Labral/Paralabral cyst 13% Acetabular bone edema 11% Fibrocystic changes of the femoral head/neck junction 22% Rim fracture 11% Subchondral cysts 16% Abnormalities in 73% Osseus bump on the femoral neck 20%
FAI and Labral Pathology - CAM lesion • Primarily in males • 14-25% males • 4-5% female • CAM deformity may be a previous silent SCFE • 710/4,731 hips
Conservative Management Emara, JOS, 2011 • 37 patients with mild FAI • alpha angle < 60º • 24 mo • HHS from 72 to 91 • VAS from 6 - 2 • 4/27 (11%) went on to surgery Yazbek, JOST, 2011 • case report 4 patients Mansell, BMC MSK dis, 2016 • RCT w/ 2 yr f/u (Protocol) Griffin, BMJ, 2016 • RCT w/ 12 mo Wright, J sci med sport, 2017 • PT vs. HEP
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