Hip Pathology Young to Old - c.ymcdn.com approx. 50% of ball ... Thick fibrous structure ... Gluteus maximus Gray's Anatomy for Students, Third Edition

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  • 10/7/2016


    Justin Wilcox PA-CMayo Clinic Arizona

    Department of OrthopedicsSports Medicine


    Hip Pathology Young to Old

    Amazing Hip





    Ilium Ischium Pubis Acetabulum Femur Sacrum

    Gray's Anatomy for Students, Third Edition

  • 10/7/2016


    Femoroacetabular Joint

    Ball and Socket Femoral Head and Acetabulum Synovial Joint Supports weight of the body

    Statically Dynamically

    Forces across the hip joint 2.5x body wt standing on

    one leg 5x body wt running



    Confluence of the Ilium, Ischium and Pubis

    Oriented inferiorly, laterally and anteriorly

    Fuse 14-16 yo Cup shaped Articular cartilage- horseshoe

    shaped Covers approx. 50% of ball

    Gray's Anatomy for Students, Third Edition

    Femur Femoral head/neck Oriented superiorly, medially and

    slightly anteriorly Greater trochanter

    Abductors attachment Lesser trochanter

    Iliopsoas tendon attachment

    Gray's Anatomy for Students, Third Edition

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    Femoral Neck Angle

    Angle between the axes of the femoral neck and shaft

    Changes in FNA can change the stress pattern on the hip joint

    Coxa Norma Normal 150 newborn 126 Adults

    Coxa Vara Small Angle 135 Associated with genu varum



    Labrum and Capsule

    Labrum Rubber-like fibrocartilage around the rim

    of the acetabulum Deepens the hip socket Acts as the suction seal contributes to

    stability Regulates fluid in and out of the joint Triangular in shape

    Capsule envelope Thick fibrous structure (0.7mm 4.2mm) Longitudinal and circular fibers Ligaments enclose the hip Primary source of soft tissue static




    Ligaments Makes up the hip capsule Prevent excessive ROM Extracapsular Ligaments

    Illiofemoral (Y ligament) Strongest in the body Prevents adduction and IR Prevents posterior trunk

    motion in standing Relaxed during sitting

    Ischiofemoral Prevents IR

    Pubofemoral Prevents abduction and IR

    Zona Orbicularis Collar around femoral neck

    Intracapsular ligament Ligamentum teres

    Attached at the acetabular notch to the fovea of femoral head

    Stretched with instability/dislocation

    Supplies blood to the femoral head in infants

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    Blood Supply

    Three main blood supplies:

    Retinacular vessels from the lateral femoral circumflex artery and inferior metaphyseal artery

    Interosseous circulation with in the marrow spaces running distal to proximal

    Ligamentum teres artery

    Gray's Anatomy for Students, Third Edition

    Innervation Femoral Nerve

    Originates L2-L4 Innervates all muscles of anterior thigh Skin of anterior thigh, anteromedial

    knee, medial leg, medial foot Obturator Nerve

    Originates L2-L4 Innervates muscles of medial thigh

    (except adductor Magnus/pectineus) Innervates obturator externus Skin medial upper thigh

    Sciatic Nerve Originates L4-S3 Largest nerve in the body Common fibular nerve and tibial nerve

    branch Innervates muscles in the posterior

    thigh Part of adductor magnus All muscles in leg/foot Skin lateral/ lateral side and sole of foot

    Gluteal Nerves Superior L4-S1

    Gluteus medius, minimus and TFL Inferior L5-S2

    Gluteus maximus

    Gray's Anatomy for Students, Third Edition

    Muscle of the hip 27 Muscles cross the hip joint Gluteal Group Extension and abduction

    Gluteus maximus Gluteus medius Gluteus minimus Tensor fasciae latae

    Adductor Group Adduction and hip flexion Adductor Brevis Adductor Longus Adductor magnus Pectineus Gracilis

    Iliopsoas Group Hip flexors Iliacus Psoas Major Sartorius Tensor Facia Latae

    Lateral Rotator Group External rotation Externus and internus obturators Piriformis Superior and inferior gemelli Quadratus femoris

    Other Rectus femoris hip extension, knee flexion Sartorius Hamstring muscles Gray's Anatomy for Students, Third Edition

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    Timing of Symptoms Acute injury/event Chronic/insidious

    Location Groin C sign Deep Lateral Gluteal or trochanteric Deep vs. Superficial

    Quality Sharp Dull Ache Throb

    Radiation Anterior thigh Buttocks Lateral Lumbar


    Mechanical Symptoms Locking Catching Popping Snapping



    Differential Diagnosis

    Lumbar pain Sports hernia SI joint pain Piriformis syndrome Adductor tear GI issues GU issues Gynecologic problems


    AP Sitting Standing


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    45 degree Dunn view False profile view

    Femoro-Acetabular Impingement (FAI)

    Describe in literature for nearly 100 years More common in females Most commonly a mixed pattern Abnormal contact between the ball and socket During hip ROM (Flex, ADD, IR) non-spherical

    head and over covered socket, hit or rub against each other

    Pinch the labrum Leading to degeneration or tearing of the labrum Can lead to labral tears and advancement of OA

    Three forms: Pincer, Cam and Combined


    Pincer Lesion

    Prominent, over-covered socket, acetabular depth or malalignment

    More common in middle age females

    Anterosuperior most common

    Acetabular retroversion

    Prominent AIIS due to apophyseal traction injury of the rectus femoris before skeletal maturity

    Global over coverage- deepened acetabulum

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    Cam Lesion

    Non-spherical femoral head and neck More common in females, athletes Bimodal age

    20s 40s

    Higher incidence in high-impact sports Basketball Soccer

    Etiology- possible due to stress at the lateral epiphysis of the femoral head during adolescence

    Flexion- prominence of the head rotates into acetabulum, causing a shearing force on the acetabular surface anterolateral

    Articular delamination, labral tearing, develop OA

    Degree of pathology varies Severity of cam Intensity of exposure

    Combined Impingement

    Features of both Cam and Pincer 86% patients with impingement

    Superphysiologic motion with normal radiograph Ballet Gymnastics


    Signs and Symptoms

    Acute Event or Insidious Onset Groin Pain dull or sharp C sign pain deep between fingers and

    thumb Lateral Pain Catching, locking or clicking Giving way Worsening pain:

    Prolonged sitting, standing, walking Stair climbing In and out of car or low chair Putting on shoes/socks Rotational activities

    Journal of Sport Rehabilitation, 2009, 18, 3-23

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    Physical Exam

    Inspection Leg length discrepancy Pelvic obliquity Muscle contracture Atrophy Scoliosis

    Stance/Gait Antalgic gait Trendelenburg gait Single leg stance

    Palpation L-spine SI joints Ischium Iliac crest Greater trochanter Trochanteric bursa Muscle bellies Pubis symphysis

    Hip Physical Exam

    Range of motion Flexion

    120 Extension

    0-10 Abduction

    45 Adduction

    20-30 Seated Internal rotation

    20-35 Seated External rotation


    Neurovascular Motor strength Sensory L2-S1 DTRs Vascular assessment

    Objective/Physical Exam Reduced hip flexion, IR and adduction Weakness of gluteus medius, minimus and

    iliopsoas Pain with palpation:

    Iliopsoas Gluteals External rotators Tensor fascia lata

    Special tests Anterior Impingement test (FADDIR

    flexion, adduction and internal rotation)

    Complain of deep groin pain with decreased ROM

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    Lateral/Abduction Impingement Test

    Posterior Impingement Test

    FABER Groin iliopsoas strain/impingement Posterior SI joint Lateral pertirochanteric space


    X-Rays Cam Impingement

    Cam bump Alpha angle

    Contour of femoral head/neck >50-55 degrees

    Pincer Impingement Crossover sign Focal over coverage (focal

    retroversion) Global over coverage (coxa profunda

    or protrusio) Combined Impingement


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    Lateral center edge angle Degree of acetabular

    coverage over the femoral head

    Normal 25-40 Borderline 20-25 Dysplasia 40

    MRI Findings

    Most accurate modality MRI Arthrogram Obtain if concerned of a labral tear +/- Labral tear +/- Cartilage injury Stress fracture Predicts outcomes of arthroscopy based on

    state of cartilage


    NSAIDs Activity modification Physical therapy

    Minimum 8-12 weeks 2-3 x/wk with HEP

    Diagnostic intra-articular injection 1% lidocaine

    Arthroscopic surgery 3-4 month recovery

    Alan M. Hirahara, M.D., FRCSC

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    Intra-articular Injection

    1% Lidocaine

    Lidocaine + Corticosteroid

    Hyaluronic Acid

    Physical Therapy

    Proprioceptive/balance training Functional training Manual therapy Flexibility training Strength trai


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