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10/10 walking at conference, sat on bench, went to get up and has severe pain x 4 hours, then resolvedMid 11/10, rolled over in bed and felt sharp pain in L hip
PMH: OsteoporosisReferred by PCP to address L hip pain and decreasing functional statusFunctionally
Increased pain with walkingAM stiffnessInability to play golf or exercise
PT Examination
R/i L Hip OA Cluster for the Identification of Hip OA
Cluster 2Painful hip with IR> 50 yoMorning stiffness < 60 min
Diagnostic AccuracyAll 3 component of cluster are present: + LR = 3.4
Evaluation/Plan of Care
Differential Pathologic Diagnosis:OA L hipStress Fx due to underlying h/o osteoporosis
Referred to Orthopedist for medical work-upRadiographyMRI
Non-traumaHip Pain ImagingPathway
www.imagingpathways.health.wa.gov.au
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Selection of Imaging Studies
RadiographyIntegrity of joint structuresR/i or R/o DJD
MRIIntegrity of soft tissue structuresR/i or R/o insufficiency fx
Plain Films
2010AP & Lat
2011AP B Hip / PelvisUnilateral AP
Plain Films - 2010
AP UnilateralLat View
Plain Films 2011
AP Pelvis
Plain Films 2011
AP L Hip
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Lat View 2011
RadiologyEvidence Based Practice
Least expensive studyAbility to assess osseous structures and evidence of pathology
Radiograph – strong additional valueThose at high risk for progression of hip OA
Kellgren - Lawrence ScoresStrongest predictor for progression of hip OA
Pts with existing hip painReijman et al: BMJ, 2005
MRI – T1 Coronal MRI T2 Coronal
MRI
Evidence Based PracticePossible associations between MRI –detected pathology and clinical sx Severe OA
Strong association with radiographic finding
Roemer et al: Osteoarthritis Cartilage. 2011
Use of Imaging StudiesDifferential Pathologic Diagnosis
Confirmation of Hip OAAppropriate PT management
Joint Distraction vs. GlidesCore Strengthening
Surgical Candidate Pt decided to wait and utilize conservative PT management
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S/p THA
Acetabular Labral Tear
Patient Profile
25 yo male Training for Boston MarathonReferred for dx of L post-medial shin splints by PCPDuring history, reported increasing R hip pain over past 5 weeks which also limited his ability to run.
PT Examination
R/i post-medial shin splintsExamination of R hip:
ROM WNL except for c/o pain with OP into hip flexion, ER>IRMuscle Performance 5/5 + pain with flexion+ Scour Test+ Anterior Labral test
Evaluation/Plan of Care
Differential Pathologic Diagnosis:Anterior labral tearDJD R hip
Referred to Orthopedist for medical work-upRadiographyMRI (with/without contrast)
Selection of Imaging Studies
RadiographyIntegrity of joint structuresR/i or R/o DJD
MRIIntegrity of soft tissue structures? Acetabular Cyst vs. Labral Tear
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Radiography
AP View Bilateral AP View
Radiography
Evidence Based PracticeLeast expensive studyAbility to assess osseous structures and evidence of pathology
MRI – T2 Weighted
Axial View
MRI
Evidence Based PracticeStrong correlation between MR imaging and pathology
Holder et al: Am J Roetgenol, 1995
MR ArthrographyExploits the natural advantages gained from joint effusion
Use of Contrast
Coronal View
MR ArthrographyEvidence Based Practice
T2-weighted imagesCadaveric Study (Holder et al: Am J Roetengenol, 1992)
Differential Pathologic DiagnosisConfirmation of Anterior Labral Tear
Not appropriate PT managementSurgical Candidate
Osseous Injuries
Stress Reaction ResponseStress (Fatigue) FxInsufficiency Fx
Hip Fx Imaging Pathway
www.imagingpathways.health.wa.gov.au
Stress reaction (response)
Represents microtrabecular fractureNormal or near normal radiographsBone marrow edema pattern on MRTypically on inferomedial aspect of femoral neckNo discrete linear component
T2 Fat Suppressed Axial
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Bone Scan Fatigue (Stress) fracture
MRRound or ovoid hypointensity on T1 and hyperintensity on T2Associated linear signal abnormalityLinear component may be most visible on T1 or T2