Advances in Diagnosis and Treatment of Hip Injuries

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

I have no relevant disclosures.

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Most Common Hip Pathologies

 STAIRS  Stress Fracture

 Trochanteric Pathology

 Arthritis  Impingement

 Referred pain

 Snapping hip

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Big 3- Questions to Ask

 Chronicity- When did it happen?

 Mechanism- How did you injure it?

 Location- Where is the pain?

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Chronicity

 Acute  Chronic

•  Overuse

•  Repetitive microtrauma

•  Degenerative

•  No specific injury

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Mechanism of Injury

 Contact  Non-contact

•  Twisting

•  Squatting

•  Flexion/extension

•  “Pop”

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Location, Location, Location  Buttock/posterior

•  Low back/sciatic nerve

•  Referred pain

 Lateral/thigh

•  Trochanteric pathology

•  Snapping hip

 Anterior/groin

•  Arthritis

•  Impingement (FAI)

•  Stress fracture

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Anatomy

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Intra-articular Anatomy

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

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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

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Trochanteric Pathologies

 Trochanteric bursitis

 Gluteus tear

 All have lateral sided hip pain

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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

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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

 Tredelenburg sign

 Treatment

•  PT, CSI

•  If no improvement then endoscopic gluteus repair is an option

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Physical Exam

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Hip Abduction Testing

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

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Clinical Presentation

 Physical Exam

•  Decreased range of motion

•  Pain in groin, lateral and posterior

•  Crepitus with ROM

•  Altered gait

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Radiographic Findings

 AP Pelvis

•  Joint space narrowing

•  Subchondral sclerosis

•  Osteophytes

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Treatment

 Conservative

•  Physical Therapy

‒ Gluteal and core strengthening

•  Cortisone injection

‒ Ultrasound or fluoroscopic guidance

 Operative treatment

•  Total hip arthroplasty

‒ Anterior, anterolateral, posterior approach

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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

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FAI

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

Hip Labral Tear- can be acute event

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FAI- Common symptoms

 Pain

•  Anterior groin and in c-shaped band

•  Worse with prolonged sitting

•  Sit to stand

•  Activity related (walking, running, jumping, squats)

•  Pts may complain of hip tightness or inflexibility

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Physical Exam

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•  Flexion, adduction, internal rotation of hip causes pain

Imaging

 Radiographs (AP pelvis, Dunn Lateral)

 MRI/MRA

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MRI- can show labral/cartilage injury

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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

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FAI Acquired During Skeletal Maturation in Athletes

 Agricola et al AJSM 2014 •  63 pre-professional

soccer players in Netherlands

•  Baseline Xray at age 12 showed 2% with Cam

•  F/u xrays 2 years later showed 18% with Cam

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FAI and Arthritis

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

Treatment

 Conservative treatment is 1st line

 Rest

 PT- core strengthening, gluteal strengthening

 If fails PT then intra-articular CSI

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Intra-articular injection of anesthetic/steroid

 Ultrasound or fluoroscopically guided intra-articular corticosteroid injections commonly used in US

 Can help to localize an intra-articular source of hip pain

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CSI for Hip Pain

•  Diagnostic modality for localization of source of pain

‒ 90% accuracy (Byrd et al 2004)

•  Therapeutic effect

‒ Pain improvement variable duration (2 weeks to 2 months)

Surgical Treatment- Hip Arthroscopy

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Cam Decompression

Pre-op Post-op

Alan Zhang, MD UCSF Hip Arthroscopy

Pincer Decompression

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Labral Repair

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Labral Repair

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 20,484,172 unique orthopedic patients analyzed

 8,227 hip arthroscopy cases

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Outcomes

 Byrd et al 2011

 200 athletes with 2 year follow up after hip arthroscopy

 90% returned to sport (95% pro, 85% collegiate)

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Does FAI Surgery Prevent Arthritis?  Quantitative MRI to assess for early cartilage injury in hip

 NIH funded study at UCSF- actively recruiting patients

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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

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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

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Snapping Hip

 External snapping hip (lateral) •  More common

•  IT band catching on greater trochanter

•  Dancers, runners, soccer players

 Internal snapping hip (groin) •  Iliopsoas snaps over the lesser trochanter or AIIS

 Treatment •  PT- Rest, stretching, foam roll

•  Rarely- surgery for endoscopic IT band or iliopsoas release

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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

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Iliopsoas Snapping/tendinopathy

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•  Low pitched snap on flexion to extension of hip (Thomas test)

•  Tender on deep palpation of anterior groin

•  Sore with hyperflexion of

hip

 Stress Fracture •  Female athlete triad

 Trochanteric Pathology •  Bursitis, gluteus tear

 Arthritis •  Osteoarthritis, rheumatoid

 Impingement •  FAI, Labral tears

 Referred pain •  Lumbar spine/knee

 Snapping hip •  IT band, Iliopsoas

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STAIRS Thank you

 Alan Zhang, MD

 alan.zhang@ucsf.edu

 415-353-4843

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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.

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