What’s Hip - UCSF CME · • If no improvement then endoscopic gluteus repair is an option 13 ... Goodwin RC. Injuries about the hip in the ... pathology and how structure determines

[ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]

12/11/20151

What’s Hip:Top 5 Hip Problems in Primary Care

Alan Zhang MDAssistant ProfessorSports Medicine and Hip ArthroscopyUCSF Department of Orthopaedic SurgeryDecember, 2015

I have no relevant disclosures.

2

Top 5 (or 6) Pathologies�STAIRS

�Stress Fracture

�Trochanteric Pathology

�Arthritis

� Impingement

�Referred pain

�Snapping hip

3

Big 3- Questions to Ask�Chronicity- When did it happen?

�Mechanism- How did you injure it?

�Location- Where is the pain?

4


12/11/20152

Chronicity �Acute

�Chronic

• Overuse

• Repetitive microtrauma

• Degenerative

• No specific injury

5

Mechanism of Injury�Contact

�Non-contact

• Twisting

• Squatting

• Flexion/extension

• “Pop”

6

Location, Location, Location�Buttock/posterior

• Low back/sciatic nerve

• Referred pain

� Lateral/thigh

• Trochanteric pathology

• Snapping hip

�Anterior/groin

• Arthritis

• Impingement (FAI)

• Stress fracture

7

Anatomy

8

Intra-articular Anatomy


12/11/20153

Stress Fracture�Acute on chronic injury

�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

9

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

10

Trochanteric Pathologies�Trochanteric bursitis

�Gluteus tear

�All have lateral sided hip pain

11

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

12


12/11/20154

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

13

Physical Exam

14

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

15

Clinical Presentation�Physical Exam

• Decreased range of motion

• Pain in groin, lateral and posterior

• Crepitus with ROM

• Altered gait

16


12/11/20155

Radiographic Findings�AP Pelvis

• Joint space narrowing

• Subchondralsclerosis

• Osteophytes

17

Treatment�Conservative

• Physical Therapy

‒ Gluteal and core strengthening

• Cortisone injection

‒ Ultrasound or fluoroscopic guidance

�Operative treatment

• Total hip arthroplasty

‒ Anterior, anterolateral, posterior approach

18

Impingement

�Femoroacetabular Impingement (FAI)

�More commonly chronic injury (can be acute)

�Age group 15 to 55 years old

�Pain- groin/anterior or C-shaped band over the hip

�Worse with prolonged sitting

19

FAI�Abnormal bony anatomy that forms during development

• Intense sports during childhood may be associated

• Can lead to intra-articular injury to labrum and cartilage

• Can lead to early arthritis

20


12/11/20156

FAI

21

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

Hip Labral Tear- can be acute event

22

Physical Exam

23

• Flexion, adduction, internal rotation of hip causes pain

Xrays

24


12/11/20157

Radiographic Measurements

25

Alpha angle and head-neck offset Lateral Center Edge Angle and Cross-over sign

MRI- can show labral/cartilage injury

26

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

27

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

28


12/11/20158

FAI and Arthritis

29

• 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

30

Surgical Treatment- Hip Arthroscopy

31

Cam Decompression

32


12/11/20159

Labral Repair

33

Labral Repair

34

Incidence of Hip Arthroscopy

36

Zhang et al 2015 Outcomes�Byrd et al 2011

� 200 athletes with 2 year follow up after hip arthroscopy

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

37


12/11/201510

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

�NIH funded study at UCSF- actively recruiting patients

38

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

39

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

40

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

41


12/11/201511

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

42

Iliopsoas Snapping/tendinopathy

43

• 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

44

STAIRS Thank you�Alan Zhang, MD

� [email protected]

� 415-885-3832

12/11/2015Pediatric Hip Injuries45


12/11/201512

References1. 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.

12/11/2015Pediatric Hip Injuries46

Documents

What’s Hip - UCSF CME · • If no improvement then endoscopic gluteus repair is an option 13 ... Goodwin RC. Injuries about the hip in the ... pathology and how structure determines