The Athletic Hip

The Athletic Hip:Common Diagnoses and Minimally Invasive Treatments

Sanjeev Bhatia MDOrthopaedic Surgeon - Sports Medicine

Co-Director, Hip & Knee Joint Preservation CenterNorthwestern Medicine West Region

Team Physician, Northern Illinois University

Disclosures

No Pertinent Disclosures to this Talk

• Royalties with Nova Publishing - Ligamentous Injuries of the Knee, BMJ Publishing Group- “Medial Collateral Ligament Injuries”

• Stock and Ownership – Joint Preservation Innovations, LLC; Vericel; Intuitive Surgical, EDGe Surgical

• Consultant – EDGe Surgical

Hip and Knee Joint Preservation:

Because there is no substitute for your own joints

Why Joint Replacements are not Good for Younger People

Surgical Risks

Infection

Fracture

Dislocation

Blood clots

Functional Limitations

Permanently low demand

Altered mechanics with any artificial joint

Need for revision surgery

Costs to SocietyCosts of Joint

replacement surgery

Costs of revision surgeries

Costs of complications

Economic loss of productivity

“Nothing is as good as the original”

Hip Pain is Common

Early Hip pain suffers a significant inequality!

400,000 Total Knee Replacements600,000 Total Hip ReplacementsOver 1 Million Knee ArthroscopiesOver 600,000 Shoulder

Arthroscopies70,000 Hip Arthroscopies

2013 Data

Causes of Hip and Groin Pain

– Anterior Hip Pain• Muscle strains• Contusion (hip pointer)• Avulsions and apophyseal injuries• Hip dislocation/subluxation• Acetabular labral tears and loose bodies• Proximal femur fractures• Osteitis pubis• Iliopsoas bursitis• Stress syndrome• SCFE• Perthes disease• Developmental dysplasia• Osteoarthritis• Inflammatory Arthritis• Avascular Necrosis• Femoro-acetabular Impingement

– Lateral Hip Pain:• Greater trochanteric bursisits• Gluteus medius/minimus tear• ITB syndrome• Meralgia paresthetica

– Posterior Hip Pain• Lumbar spine abnormalities• Compression neuropathies• Piriformis syndrome• SI joint pathology• Ischial bursitis• Proximal hamstring strain/rupture

– Other Causes of Hip Pain:• Abdominal (sports hernias and athletic pubalgia, inguinal hernias, appendicitis)• Gynecologic (ovarian cysts, PID, pregnancy)• Urologic (testicular, scrotal)• Genitourinary (kidney stone, nephritis)

Burnett, Clohisy et al. JBJS 2006

•Average time from injury to accurate diagnosis 21 months

•Average of 3.3 providers seen before definitive treatment

Diagnostic Approach

Many sources of potential pain – So, what is the best way to tackle hip pathology?

1. Know your anatomy!

2. Identify the Location or Area of Discomfort

Intra-articular cause

Extra-articular cause

Microinstability Referred Pain

Painful Hip

Acetabulum Up Close….

Acetabular Labrum

• Deepens the socket

• Provides a fluid seal

• Injured at the chondro-labral junction

• Critical for normal hip function

Hip Capsule – Zona Orbicularis increases stability during extension

Zona orbicularis (thick ring in capsule) tightens in extension

Courtesy of Damian Griffin MD (United Kingdom)

JBJS Am 2014

BMC Musculoskeletal

Disorders 2014

Clinical & Radiographic Evaluation

Diagnostic Approach

Many sources of potential pain – So, what is the best way to tackle hip pathology?

1. Know your anatomy!

2. Identify the Location or Area of Discomfort

Layered Understanding of the Hip

Osteochondral Layer

Femur/Acetabulum

Dynamic Impingement (FAI)

Static Overload (Dysplasia)

Inert LayerLabrum, Capsule,

Ligaments

Dynamic Layer

All musculature

Pain from entesopathies

Neural LayerNerve compression

syndromes, referred pain

Curr Rev Musc Med 2012

Posterior / Buttock

Lateral

Anterior / Groin

Anterior Hip Pain

Anterior Hip Pain

• Extra-articular

• Intra-articular

Anterior Hip Pain

•Extra-articular

• Intra-articular

Extra-Articular Anterior Hip Pain:Hip Flexor Strain / Iliopsoas Tendinitis

• Anterior hip or groin pain, F>M • Aggravated with activity, relieved with rest• Pain with rising from a seated position,

walking up stairs or inclines, brisk walking • Pain may radiate down the anterior thigh

toward the knee.• Report an audible snap or click in hip or

groin = Internal Snapping Hip

Extra-articular Anterior Hip Pain:Hip Flexor Strain / Iliopsoas Tendinitis

Internal Snapping Hip

Iliopsoas Tendon snaps over Acetabular rim / AIIS

“Can hear it”

Treatment1. Anti-inflammatories2. Injections3. Physical Therapy4. Surgery rarely indicated

91% elite ballet dancers with painless snapping

Anterior Hip Pain

• Extra-articular

• Intra-articular

“C” sign

Groin – 75%

Worse with:

• start-up activities

• prolonged sitting

• prolonged activity or sports

• uphill, putting on shoes

• getting in and out of car

Can be ATYPICAL!

• Associated symptoms

Catching or locking

Instability

Stiffness

Intra-Articular Hip Pain

Most Common Causes of Intra-Articular Hip Pain

If the age of the patient is:

• >50 years, think:

– Osteoarthritis

• <50 years, think:

– FemoroacetabularImpingement (FAI)

– Labral Tear

Anterior Hip Pain Muscle strains Contusion (hip pointer) Avulsions and apophyseal

injuries Hip dislocation/subluxation Acetabular labral tears and

loose bodies Proximal femur fractures Osteitis pubis Iliopsoas bursitis Stress syndrome SCFE Perthes disease Developmental dysplasia Osteoarthritis Inflammatory Arthritis Avascular Necrosis Femoroacetabular

Impingement

Why do young patients (ages 20-50) with apparently normal anatomy

develop arthritis of the hip?

• Hip conditions, in most cases, can be though of as being on a spectrum

• Conditions range from preclinical disorders with early symptoms and radiographic findings to those that result or have led to clear degeneration of the hip

Normal Hip

•Good cartilage and labrum

Preclinical Hip problems

•Femoroacetabular impingement (FAI) with Labral Tear

•Acetabular Dysplasia

End stage arthritis

•Complete loss of joint space

•"Bone on Bone" arthritis

Cam Dominant FemoroacetabularImpingement (FAI)

”Pistol Grip” Femur - Stulberg and Harris 1975

• Stulberg SD, Cordell LD, Harris WH, Ramsey PL, MacEwen GD. Unrecognized childhood hip disease: a major cause of idiopathic osteoarthritis of the hip. In: The hip: proceedings of the third meeting of the Hip Society. St. Louis, MO: Mosby, 1975:212–228.

• FAI occurs when the femoral neck

and acetabular rim abut at the

extremes of motion due to deformity of

the femoral neck (CAM), acetabulum

(pincer), or both

• FAI leads to early OA

• Prevalence of FAI = 15%

• Up to 70-90% of ALL hip arthritis

cases thought to be caused by FAI or

hip dysplasia

British J Sports Med 2016

- Best summary on FAI syndrome

for patients, healthcare providers

- International consensus statement


What is FAI syndrome?

• A motion-related clinical disorder of the hip with a triad of symptoms, clinical signs and imaging findings.

• It represents symptomatic premature contact between the proximal femur and the acetabulum

Femoroacetabular Impingement

Due to a mismatch between ball (femoral head) and cup (acetabulum)

CAM Lesion


• Due to a overcoverage of the acetabulum with a normal femoral head/neck

Pincer Lesion

Etiology of FAI

Genetic / Inherited

➢ Siblings of patients with CAM deformity have 2.8x RR of having same deformity

➢ Siblings of patients with Pincer deformity have 2.2x RR of having same deformity (Pollard JBJS Br 2010)

• Acquired

• Athletes with Open physes increased risk of CAM lesion compared to non-athletes

85% of patients with sxatic FAI have bilateral bone abnormalities, 25% symptomatic on other side


Typical patient:➢ Young Active Adults ➢ Athletes ➢ Runners ➢ Dancers

Symptoms

Anterior Hip / Groin Pain

Worse with flexion activities, sitting for long periods of time

Limited motion (flexion, IR)

Clicking or locking of the hip or a feeling of hip suddenly “giving out.”


Clinical Signs

• Hip impingement tests usually reproduce pain

• The most commonly used test, FADIR test, is sensitive but not specific

• There is typically restricted internal rotation in flexion.

Clinical Exam


Diagnostic imaging

• An AP pelvis and a lateral femoral neck view

• Can quickly review joint space, identify cam or pincer morphologies

• Advanced imaging shows cartilage, labral lesions, and bone pathology

Always Assess Joint Space on a Standing AP Radiograph – Make sure arthritis not already advanced!

Measure this space

Ideally want >3mm Joint space with no subchondral cysts

CAM Deformity

On plain AP radiographs, this pathology may easily be missed.

CAM Deformity

• Alpha angle on Dunn lateral

radiograph.

– Normal = 42º

– CAM > 50º

• Alpha angle = Poor

interobserver reliability

(0.40) Nepple, Philippon AJSM 2014

a

Nötzli, H et al. JBJS, 84-B:556, 2002.

MRA and CT

• MRI:

– Labral tears

– Articular cartilage lesions

– Herniation pits

– Sensitive + Specific

for Chondral Lesions but not labral pathology

• CT (Preoperative Planning):

– Detailed bony anatomy

– Acetabular and femoral neck road map

Treatment


What is the appropriate treatment of FAI syndrome?

• Activity modification, rehabilitation or surgery

• Rehabilitation aims to improve hip stability, neuromuscular control, strength, ROM and movement patterns

• Surgery, usually arthroscopic, aims to improve the hip morphology and repair damaged tissue

Griffin DR. British J

Sports Med 2016

Treatment – My Initial Approach

Conservative, non-surgical treatment is ALWAYS the first course of action in treating hip pain.

This includes anti-inflammatories, physical therapy, chiropractic therapy and injections.➢ Diagnostic/Therapeutic Injections

• Huge part of my decision-making and treatment protocol • Intra-articular U/S guided lidocaine / cortisone injection• 90% accuracy for determining intra-articular pathology

Non-operative Treatment

1. Treat inflammation➢ Oral NSAIDS, steroids➢ Injections

2. Address functional deficits➢ Physical therapy➢ Chiropractic therapy

3. Reduce aggravating factors➢ Sitting➢ Running

Intra-articular Hip Injections

Indications

FAI Syndrome

Osteoarthritis

Diagnostics

Injection types

Steroid + Numbing

agent

PRP

Visco off label

Cost Effective

Real Time Diagnostics and Therapeutic in office

Ultrasound Guided Hip Intra-articular Injections

Fluid

Success Rates of Nonoperative Tx

Intra-ArticularLabral tears/FAI/OA

• Less than 50% success

• PT alone often worsens symptoms

• Maximum one intra-articular injection

• Careful about prolonged pain and dysfunction

Extra-ArticularMuscle strain/snapping hip

• > 90% success

• PT is hallmark of treatment

• Focus on strengthening and stretching of opposing muscle groups

• Pelvic tilt / balance re-training

“Hey Doc, I have FAI and a labraltear but therapy has made it

worse! What’s the next step???

Treatment

If fail to improve with nonoperative treatment modalities, consider surgery

Hip Arthroscopy

vs

Open Hip Surgery

Hip Arthroscopy Indications

Who is the Ideal Patient for Isolated Hip Arthroscopy? Greater than 2mm (Ideally > 3mm) of joint space on

standing AP Pelvis radiographs Tonnis Grade 0 or 1 Intra-articular symptomatic FAI syndrome

➢ Hip and groin pain with symptoms that occur during hip flexion and/or internal rotation

➢ Limitations in ROM compared to c/l side

Failed physical therapy +/- injection No dysplasia or severe hip instability

Hip Arthroscopy – What Can I Treat?

FAI Labral Tears Cartilage Defects Loose Bodies Septic Joint Abductor Tears Iliopsoas tendon release Trochanteric Bursectomy

and IT band resection

Hip Arthroscopy - Portals

Portal Placement Typically use

2-3 Portals

Hip Arthroscopy - Access

AL Portal least traumatic way to access central compartment

Spinal needle Nitinol Wire 4.5mm Cannula Scope

Avoid piercing labrum and hitting femoral head

Hip Arthroscopy – Capsulotomy

Basic Technique Cut the capsule

to allow intra-articular mobility and visualization

Hip Arthroscopy - Technique

Expose the anterior and superior labrum.

Necessary for labral repair or removal of bone


Remove bone from anterior superior acetabulum

Repair labrum

Labral Treatment Algorithm During Hip Arthroscopy

Address FAI

• Very important to concomitantly address

• 96% labraltears due to FAI

Labral Repair

• Most cases labrum torn

• Usually use 3-4 anchors

• Preservation of labrum truly joint protective

Labral Debridement

• Done in situations of labral degeneration when suction seal intact

LabralReconstruction

• Rarely needed

• Mostly for revision cases

• Can use allograft or autograft

• Kite Technique


Remove the impinging CAM lesion

• No guidelines to define CAM

correction goal

• Excessive bone resection can

compromise suction seal or structural

integrity of femoral neck

• Can be difficult to translate 2D

perspectives seen on preoperative AA

assessment to 3D FAI assessment

• Intra-op assessment may be easier

and more fruitful in guiding resection

Preoperative Dynamic Exam

Postoperative Dynamic Exam (same patient)

Intra-op Dynamic Exam to Guide Cam Resection

What Works?

• Early PROM and Hip Arthroscopy Specific Rehab

What Doesn’t Work?

• Limited Rehab without PROM

Hip Arthroscopy

• 1264 hip arthroscopy surgeries

• Patients undergoing rehab without circumduction were 4.2x more likely to have symptomatic intra-articular adhesions seen during revision arthroscopy

KSSTA 2014

40F with capsulolabral adhesions

4 Phases of PT Protocol

1. Protection = Weeks 0-4➢ PRICE➢ CPM, FFWB 20# x 2-3 wks, Hip Brace➢ Avoid Hip Flexor Irritation

2. Initial Strengthening = Weeks 4-10➢ Non-compensatory gait and

progressions➢ Aquatic program if possible

3. Advanced Strengthening ➢ Week 10 – Sports Test Completion➢ Return to Pre-Injury Level of

Function4. Return to Sport

➢ Usually at 5-7 months➢ Safe and Successful RTP is Main Goal

Previous patient: 21 year old female college soccer player

Outcomes

Surgical Outcomes following hip arthroscopy for FAI

• 85-90% good to excellent results in our hands

• Durable at 5 years• Evolving techniques and

understanding• Outcomes depend on

Indications!

AJSM 2010

28 NHL Hockey players undergoing hip arthroscopy with labral repair➢ 3.4 months was avg time to return to skating➢ All players returned to sport➢ mHHS 7095

AJSM 2017

87% (52/60) returned to play professional football after hip arthroscopy

➢ Athletes who returned went on to play an average of 3.2 seasons after surgery

• 21yo Div 1 collegiate basketball player planning to play professionally

• 6 mo right hip pain

• Failed 6 mo of PT, injections, cessation of sports

Case 1

Large cam

lesion

Labral

tear

• Labral repair

• Femoral osteoplastySurgery

Labrum being repairedLabral tear with Grade III

chondromalacia

• Labral repair

• Femoral osteoplastySurgery

Femoral

osteoplastyFocal cam

lesion

Outcome – 1.5 years post-op

Preoperative sharp pain gone within first 2 weeks

Back to dunking and cutting

Playing basketball professionally overseas

Instrument Preop 3 mopostop

12 mopostop

mHHS 67 91 100

Vail Hip Score 53 89 100

HOS-ADL 81 99 100

HOS-Sport 78 100 100

• 42yo male with 2 years of hip pain and severe mechanical symptoms

• Diagnosis of synovial chondomatosis (loose bodies) on MRI

Case 2

Large loose bodies –

synovial chondromatosis

• Labral repair

• Femoral osteoplasty

• Microfracture of acetabularcartilage defect

• 35 Loose bodies removed (synovial chondromatosis)

Surgery

10x10 loose bodies throughout jointLabral tear with Grade IV

chondromalacia

• Labral repair

• Femoral osteoplasty

• Microfracture of acetabularcartilage defect

• 35 large loose bodies removed (synovial chondromatosis)

Surgery

35 loose bodiesLabral repair

Summary

Hip pain is common and commonly missed

➢ C-sign or groin = intra-articular, but can be atypical

Location, location, location

➢ Anterior/Groin with C-sign – Intra-articular

➢ Lateral – Trochanteric Bursitis/Gluteus mediustendinopathy

➢ Posterior/Buttock – Lumbar spine pathology/SI joint

Summary

Physical Therapy always first line treatment

➢ Injections PRN - can be used diagnostically and therapeutically

➢ PT Protocol depends on location/cause:

• FAI/Arthritis/Intra-articular pain – Posterior pelvic muscle strengthening

• Lateral hip pain/Troch Bursitis – IT band stretching, gluteus medius strengthening, soft tissue mobs

Summary

Treatments

➢ Non-operative treatment

• Greater than 90% success for extra-articular causes

• Only 50% success for intra-articular causes (FAI/OA)

➢ Surgery has excellent results in right hands (90% good to excellent)

• Hip Arthroscopy

• PAO indicated when dysplasia +/- Microinstability

Hip Preservation: A Team Approach!

Orthopaedic Sports Medicine

Athletic Training

Treatment

Physical Therapy

Joint Replacement

NM West RegionHip & Knee Joint Preservation Center at CDH

• NM West Region Hip & Knee Joint Preservation Center aims to provide patients from the Midwest region and beyond with a cutting edge, multidisciplinary approach to optimizing joint function

• Goal is to provide patients with the best evidence-based non-arthroplasty treatment for relieving hip and knee pain, especially those experiencing accelerated progression towards end stage arthritis


• A true multidisciplinary approach to optimizing joint function

- MSK Radiology

- PM&R

- PT

- Chiropractic Care

- Primary Care Sports Medicine

- Ortho Sports Medicine

- Rheumatology

- Adult Reconstruction

Current Research Initiatives

• Create a robust database with computerized patient reported outcomes collection and surgical procedure data

Outcomes Registry Creation

• Registry will facilitate research

• Clinical studies can then be developed

Clinical Trials and Studies


• Mission:

To provide patients with the best evidence-based non-arthroplasty treatment for relieving hip and knee pain, especially those experiencing accelerated progression towards end stage arthritis

Sanjeev Bhatia MDOrthopaedic Surgeon, Sports Medicine

[email protected]

Cell 312-404-4903

Please contact us!!

mailto:[email protected]

Documents

The Athletic Hip