Whats Hip: Common Hip Problems and Kids and Adults Alan Zhang MD - - PDF document

▶
what s hip common hip problems and kids and adults
SMART_READER_LITE
LIVE PREVIEW

Whats Hip: Common Hip Problems and Kids and Adults Alan Zhang MD - - PDF document

May 08, 2023 308 likes •559 views

11/20/2017 Whats Hip: Common Hip Problems and Kids and Adults Alan Zhang MD Assistant Professor Sports Medicine and Hip Arthroscopy UCSF Department of Orthopaedic Surgery I have no relevant disclosures. 2 1 11/20/2017 Most Common Hip

slide-1
SLIDE 1

11/20/2017 1

What’s Hip: Common Hip Problems and Kids and Adults

Alan Zhang MD

Assistant Professor Sports Medicine and Hip Arthroscopy UCSF Department of Orthopaedic Surgery

I have no relevant disclosures.

2

slide-2
SLIDE 2

11/20/2017 2

Most Common Hip Pathologies

  • STAIRS
  • Strain
  • Trochanteric Pathology
  • Arthritis (and Avulsion)
  • Impingement
  • Referred pain
  • Stress Fracture

3

Big 3- Questions to Ask

  • Chronicity- When did it happen?
  • Mechanism- How did you injure it?
  • Location- Where is the pain?

4

slide-3
SLIDE 3

11/20/2017 3

Chronicity

  • Acute
  • Chronic
  • Overuse
  • Repetitive

microtrauma

  • Degenerative
  • No specific injury

5

Mechanism of Injury

  • Contact
  • Non-contact
  • Twisting
  • Squatting
  • Flexion/extension
  • “Pop”

6

slide-4
SLIDE 4

11/20/2017 4

Location, Location, Location

  • Anterior/groin
  • FAI
  • Arthritis
  • Flexor strain
  • Lateral/thigh
  • Trochanteric pathology
  • Snapping hip
  • Buttock/posterior
  • Low back/sciatic nerve
  • Referred pain

7

Anatomy

8

Intra-articular Anatomy

slide-5
SLIDE 5

11/20/2017 5

Anatomy

11/20/2017 9

Muscle insertions

Strain (Muscle Strain)

  • Most common injury in hip and pelvis
  • All ages
  • Most common location at muscle-tendon junction
  • Most prone to strain if cross 2 joints (hip and knee)
  • Hip flexors (anterior)

‒ Rectus femoris ‒ Sartorius ‒ Iliopsoas

  • Proximal Hamstrings (posterior)

11/20/2017 10

slide-6
SLIDE 6

11/20/2017 6

Muscle Strain Treatment

  • Non-operative treatment
  • Rest, Ice, Compression, NSAIDs
  • Gentle range of motion exercises when pain improves
  • Strengthening once full ROM regained
  • Return to play (RTP): 1-3 weeks

11/20/2017 11

Trochanteric Pathologies

  • Trochanteric bursitis
  • IT Band Syndrome
  • Gluteus tear
  • All have lateral sided hip pain

12

slide-7
SLIDE 7

11/20/2017 7

Trochanteric Bursitis

  • Chronic pain from inflamed trochanteric bursa
  • Pain over lateral hip
  • Pain with direct palpation of greater trochanter
  • More common in females age 40-70
  • Treatment
  • PT, CSI
  • If refractory >3 months then endoscopic bursectomy is option

13

IT Band Syndrome

  • Chronic pain over lateral thigh/hip pain from overuse
  • Age group 20-40
  • Can cause contracture/tightness- External snapping hip
  • Common in runners and bikers
  • Treatment
  • Rest, icing, stretching,
  • PT, foam roll
  • Endoscopic IT band release
  • RTP: 2-4 weeks

14

slide-8
SLIDE 8

11/20/2017 8

Gluteus Tears

  • 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
  • Trendelenburg sign
  • Treatment
  • PT, CSI
  • Endoscopic gluteus repair is an option

15

Physical Exam

16

Hip Abduction Testing

slide-9
SLIDE 9

11/20/2017 9

Gluteus Medius Tear

slide-10
SLIDE 10

11/20/2017 10

Arthritis of the Hip

  • Osteoarthritis most common
  • Chronic pain, no specific injury
  • Pain in groin, anterior thigh, deep
  • Age >55
  • Rheumatoid Arthritis
  • Family history
  • Multiple joints involved
  • Age >35

20

slide-11
SLIDE 11

11/20/2017 11

Clinical Presentation

  • Physical Exam
  • Decreased range of motion
  • Pain in groin, lateral and posterior
  • Crepitus with ROM
  • Altered gait

21

Radiographic Findings

  • AP Pelvis
  • Joint space

narrowing

  • Subchondral

sclerosis

  • Osteophytes

22

slide-12
SLIDE 12

11/20/2017 12

Treatment

  • Conservative
  • Physical Therapy

‒ Gluteal and core strengthening

  • Cortisone injection

‒ Ultrasound or fluoroscopic guidance

  • Operative treatment
  • Total hip arthroplasty

‒ Anterior, anterolateral, posterior approach

23

Avulsions (Apophyseal Avulsion)

  • Occurs in Children
  • Usually non-contact, quick acceleration mechanism
  • Avulsion of bone at tendon attachment
  • ASIS- sartorius
  • AIIS- rectus
  • Ischial tuberosity- hamstring
  • Lesser trochanter- iliopsoas
  • Treatment- rest, ice, protected weightbearing (crutches) until pain

improved, ROM and strengthening, rarely surgery

  • RTP: 2-3 months

11/20/2017 24

slide-13
SLIDE 13

11/20/2017 13

Apophyseal Avulsions

11/20/2017 25

ASIS AIIS Lesser Troch

Impingement

  • Femoroacetabular Impingement (FAI)
  • Abnormal bony anatomy that forms during

development

  • Age group 15 to 45 years old
  • More commonly chronic injury (can be acute)
  • Can lead to intra-articular injury to labrum and cartilage
  • Can lead to early arthritis

26

slide-14
SLIDE 14

11/20/2017 14

FAI

27

  • Cam-Type- femoral head neck asphericity
  • Pincer Type- acetabulum overcoverage
  • Mixed Type- both Cam and Pincer

Hip Labral Tear- can be acute event

28

slide-15
SLIDE 15

11/20/2017 15

FAI- Common symptoms

  • Common Symptoms
  • Anterior groin and in c-shaped band
  • Worse with prolonged sitting
  • Activity related (walking, running, jumping,

squats)

  • Physical Exam
  • Pain with Flexion Adduction Internal

Rotation (FADIR)

29

Imaging

  • Radiographs (AP

pelvis, Dunn Lateral)

  • MRI/MRA

30

slide-16
SLIDE 16

11/20/2017 16

Prevalence of FAI in Athletes

  • Football- 90% of players at NFL Combine (2009-2010) had

at least 1 sign of FAI on xrays

  • Hockey- 75% of Elite Youth Hockey players in Colorado

had Cam lesion on MRI

  • Soccer- 72% of male and 50% of female elite soccer

players (MLS, US national team) had radiographic FAI

31

FAI and Arthritis

32

  • For patients <50 years old with hip arthritis
  • 45% due to FAI, 45% hip dysplasia, 10% trauma/other
slide-17
SLIDE 17

11/20/2017 17

Treatment

  • Conservative treatment
  • Rest
  • PT- core strengthening, gluteal strengthening
  • CSI
  • Surgical treatment
  • Hip Arthroscopy

‒ Labral repair ‒ Osteochondroplasty

33

Surgical Treatment- Hip Arthroscopy

34

slide-18
SLIDE 18

11/20/2017 18

Cam Decompression

Pre-op Post-op

Alan Zhang, MD UCSF Hip Arthroscopy

Pincer Decompression

11/20/2017 36

slide-19
SLIDE 19

11/20/2017 19

Labral Repair

37

Outcomes

  • Byrd et al 2011
  • 200 athletes with 2 year

follow up after hip arthroscopy

  • 90% returned to sport (95%

pro, 85% collegiate)

38

slide-20
SLIDE 20

11/20/2017 20

Does FAI Surgery Prevent Arthritis?

  • Quantitative MRI to assess for early cartilage injury in hip
  • NIH funded study at UCSF- actively recruiting patients

39

Referred Pain

  • Hip pain can be referred from the lumbar spine or the knee
  • Can be acute (lumbar disk herniation)
  • Usually located posterior in buttock region and radiates down the

leg

  • Age group- >40

40

slide-21
SLIDE 21

11/20/2017 21

Referred pain

  • Lumbar radiculopathy
  • Ask about radiating or shooting pain, numbness or tingling
  • Pain that shoots from the hip down past the knee is usually from

the spine and not the hip

  • Obtain L-spine films if needed
  • Knee pain
  • Femoral nerve can cause referred hip pain when source is from

the knee (and vice versa)

  • Check radiographic and knee exam if hip films and exam is

normal

41

Stress Fracture

  • Acute on chronic injury (overtraining)
  • Age group 18-60 (more commonly >40 years old)
  • Pain in groin, anterior thigh, deep in joint, worse with

weightbearing

  • PE- painful hop test
  • Females >males
  • Female athletic triad
  • Stress fracture
  • amenorrhea
  • eating disorder

42

slide-22
SLIDE 22

11/20/2017 22

Stress Fracture (Proximal Femur)

  • Sports- Track and field

most common

  • MRI or bone scan for

diagnosis

  • Treatment
  • Rest, counseling,

protected weight bearing

  • RTP: 3-4 months

43

  • Strain
  • Hip flexor/Proximal Hamstrings
  • Trochanteric Pathology
  • Bursitis, IT Band, gluteus tear
  • Arthritis/Avulsion
  • Arthritis is older adults, avulsion in kids
  • Impingement
  • FAI, Labral tears
  • Referred pain
  • Lumbar spine/knee
  • Stress Fracture
  • Female athlete triad

44

STAIRS

slide-23
SLIDE 23

11/20/2017 23

Thank you

  • Alan Zhang, MD
  • alan.zhang@ucsf.edu
  • 415-353-4843

11/20/2017 45

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.

11/20/2017 46