The Nonarthritic Hip: An Introduction...Femur, pelvis, acetabulum Purpose: Joint congruence and osteo/arthrokinetatics Pathology: Develomental Dysplasia, femoral version, acetabular

The Nonarthritic Hip:An Introduction

By Brittany Popkin, PT, DPT, SCS

What is the anatomy of the hip?○ 3 planes of motion for the osseous structures

■ Ball and socket● Sagittal● Frontal● Transverse

○ 27 muscles○ Ligaments○ Blood supply○ Nerves

What is Nonarthritic hip pain?

According to the 2014 CPG “nonarthritic hip joint pain refers to a collection of hip pain conditions proposed to involve intra-articular structures of the hip, including femoroacetabular impingement, structural instability, labral tears, chondral lesions, and ligamentum teres tears”

NO!

What are the sources of hip pain and dysfunction?

Four Layers to the Hip

Hammoud, S. et al. The recognition and evaluation of patterns of compensatory injuries in patients with mechanical hip pain. Sports health. 2014;6:108-118.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;5(1):1–8

Layer 1: Osteochondral

Layer

● Structure:○ Femur, pelvis, acetabulum

● Purpose:○ Joint congruence and

osteo/arthrokinetatics

● Pathology:○ Develomental

■ Dysplasia, femoral version,

acetabular version, femoral

inclincation and acetabular

profunda/protrusio

○ Dynamic

■ Cam/pincer impingement,

trochanteric impingement,

sub-spine impingement and

delamination

Hip X-rays

● AP pelvis○ Tonnis grades for OA

● Dunn (femoral head/neck junction)

Bedi A, Zaltz I, De La Torre K, et al. Radiographic comparison of surgical hip dislocation and hip arthroscopy for treatment of cam deformity in femoroacetabular impingement. Am J of Sports Med. 2011;39(supplement 1):20S-28S.

CT scan

● 3D model of the hip● Can assess structure of acetabulum and femur

Layer 2: Inert Layer

● Structure:○ Capsule, labrum, ligamentous

complex, ligamentum teres

● Purpose:○ Static stability

● Pathology:○ Labral tear, capsular

instability, ligamentum teres

tear, adhesive capsulitis

MRI

● T-1 weighted● Labral tears● Cartilage health

Potter HG, Sharon S, Adler RS. Imaging of the hip in athletes. Sports Med and Arthroscopy review. 2002;10:115-122

https://www.netterimages.com/hip-joint-labeled-multiple-publications-general-anatomy-frank-h-netter-4654.html

What is the purpose of the labrum?

What is the purpose of the capsule?

What is the purpose of the Ligamentum Teres?

Creates a suction seal and nutrition

of hip

Increases joint congruency

Stability

Resists motions

Iliofemoral Ligament

Pubofemoral ligament

Ischiofemoral

Stability

Keeps femoral head in socket

Layer 3: Contractile Layer

● Structure:○ Musculature crossing the hip,

lumboscaral muscles, pelvic floor

● Purpose:○ Dynamic stability

● Pathology:○ Hip flexor strain, psoas

impingement, RF impingement,

adductor tendinopathy, rectus

abdominis tendinopathy, prox HS

strain, glute med tear

27 Muscles

● Muscles support and stabilize the lumbo-pelvic complex○ Core canister: TA, multifidus, pelvic floor, diaphragm

● Hip abductors○ Primary: Glute med, min, TFL,○ Secondary: Piriformis, sartorius

● Hip adductors○ Primary: pectineus, add longus, gracilis, add brevis and add magnus○ Secondary: long head biceps femoris, glute max, quadratus femoris

● Hip flexors○ Primary: Iliopsoas, Sartorius, TFL, RF, Add longus, pectineus○ Secondary: add brevis, gracilis, anterior fibers of glur min

● Hip extensors○ Primary: Glute max, HS, adductor magnus (posterior head)○ Secondary: posterior fibers of glute med, anterior fibers of add magnus

Hip Musculature

https://www.martinpetkov.com/your-opportunity/the-hip-joint-structure-movements-and-muscles

Layer 4: Neuromechanical

Layer

● Structure:○ Thoraco-lumbar mechanics, LE

mechanics, Neuro-vascular

structures, regional

mechanoreceptors

● Purpose:○ Communication, timing and

sequencing of kinematic chain

● Pathology:○ Neural

■ Nerve entrapment, referred

spine pathology,

Neuromuscular dysfunction,

pain syndromes

○ Mechanical

■ Foot structure/mechanics,

scoliosis, pelvic posture over

femur, osteitis pubis, SI

dysfunction, pubic symphysis

pathology

Blood Supply to Hip

● Medial and lateral femoral circumflex arteries● Posterior division of obturator artery runs through lig

teres and contributes to blood supply of femoral head● Labrum - not well vascularized

○ Obturator, inferior and superior gluteal arteries

Nerve Endings in the Hip● Type I - Ruffini endings - proprioception

○ Joint capsule, periosteum, ligaments, tendons

○ Respond to stretch and stress in hip

● Type II - Pacinian corpuscles and Meissner Corpuscles - kinesthesia

○ Deep joint capsule and fat pads

○ Not in hip

● Type III - Golgi Endings - proprioception○ Intrinsic and extrinsic ligaments

● Type IV - free nerve endings - pain○ Joint capsule, ligaments, tendons, blood vessels, fat pads

○ Labrum

Kinematic Chain

● Chain has adaptive changes whether the hip is source of the dysfunction or the victim of the dysfunction

● Delayed muscle activation● Top > down● Down >top

1. Nonarthritic HipHip pathologies that relate to:

➔ Instability/Impingement

➔ Labrum, ligamentum teres, joint capsule.

➔ Soft tissue surrounding the hip

➔ Neuromechanical layer

What is a happy hip?

● Instability > Impingement● Not enough support > too much support● Excess ROM > decreased ROM● Both have muscular dysfunctions and kinematic chain

dysfunction

What is Instability?

● Extraphysiologic hip motion○ Causes pain

○ unsteadiness

● Insufficient congruency of femoral head and acetabulum○ Shallow acetabulum, decreased contact area

What is Impingement?● Intraarticular

○ Inside joint capsule

○ CAM

○ Pincer

● Extraarticular○ Outside joint capsule

○ AIIS - subspine impingement

○ GT (varus deformity as seen in

perthes hips)

Hip X-rays

● AP pelvis● Dunn (femoral head/neck

junction)● Determine AA for impingement

Bedi A, Zaltz I, De La Torre K, et al. Radiographic comparison of surgical hip dislocation and hip arthroscopy for treatment of cam deformity in femoroacetabular impingement. Am J of Sports Med. 2011;39(supplement 1):20S-28S.

Alpha Angle

Excess bump of bone >55deg

Reiman MP, Thorborg K. Clinical Examination and physical assessment of hip-joint related pain in athletes. The International Journal of Sports Physical Therapy. 2014;9(4):737-750.

Center Edge Angle

● <20 deg is considered dysplasia○ 20-25 is borderline

dysplasia

Reiman MP, Decary S, Mathew B, et al. Accuracy of clinical and imaging tests for the diagnosis of hip dysplasia and instability: A systematic review. J Orthop Sports Phys Ther. 2019;49(2):87-97.

Femoral Version

● Retroversion < 8 > Normal < 15 > Anteversion● Amount of rotation of the femur

Coxa Vara vs Coxa Valgus

● Varus angulation (<120 deg)○ Decrease joint reaction forces○ Increase shear forces across

femoral neck○ Shortening of abductor muscles;

limp

● Valgus angulation (>135 deg)○ Increase joint reaction forces○ Decrease shear forces across

femoral neck

● Normal angulation○ 120-135 deg

Bedi A, Zaltz I, De La Torre K, et al. Radiographic comparison of surgical hip dislocation and hip arthroscopy for treatment of cam deformity in femoroacetabular impingement. Am J of Sports Med. 2011;39(supplement 1):20S-28S.

Cross over sign

● Can be associated with cranial

acetabular retroversion○ pincer FAI○ focal

● True acetabular retroversion :○ posterior wall sign - post wall

of acetabulum sits medial to center of femoral head

○ ischial spine sign -

exaggerated size of ischial spine of AP radiograph medial to pelvic brim

○ Posterior instability c anterior overcoverage

Reiman MP, Thorborg K. Clinical Examination and physical assessment of hip-joint related pain in athletes. The International Journal of Sports Physical Therapy. 2014;9(4):737-750., Zaltz I, Kelly BT, Hetsroni I, et al. The crossover sign overestimates acetabular retroversion. Clin Orthop Relat Res. 2013;471:2463-2470

Coxa profunda and protrusio acetabuli

Profunda - socket is too deep,

circumferential wear pattern

Protrusio - deeper than above,

protrusion of the medial aspect of

acetabulum through iliopectineal line

Reiman MP, Thorborg K. Clinical Examination and physical assessment of hip-joint related pain in athletes. The International Journal of Sports Physical Therapy. 2014;9(4):737-750.

CT scan

● Creates 3-D picture of your anatomy

● Can see where the instability or impingement is

● Presurgical planning tool

What does this mean?

The hip is COMPLEX

2. Things to Ponder

➔ Is the hip the SOURCE of the problem?

➔ Is the hip the SITE of the problem?

➔ Is the hip the SOLUTION to the problem?.

Nonarthritic Hip Pain

Muscle strains

Tendinopathies

Athletic pubalgia

Impingement

Instability

Stress fractures

Bone or soft tissue issue that creates hip pain

Take Home Points

● Have proper education on hip mechanics and compensation patterns

● Seek appropriate medical care - PT, Physician and have appropriate tests, imaging performed

● Experience matters● Based on medical team’s

expertise, have appropriate conservative or surgical intervention performed for increased rate of success

References● Alpert JM, Kozanek M, Li G, et al. Cross-sectional analysis of the iliopsoas tendon and its relationship to the acetabular labrum.

Am J of Sports Med. 2009;37(8): 1594-1598. ● Bedi A, Zaltz I, De La Torre K, et al. Radiographic comparison of surgical hip dislocation and hip arthroscopy for treatment of

cam deformity in femoroacetabular impingement. Am J of Sports Med. 2011;39(supplement 1):20S-28S. ● Bedi A, Dolan M, Leunig M, et al. Static and dynamic mechanical causes of hip pain. Arthroscopy. 2011;27(2):235-251. ● Bedi A, Kelly BT, Khanduja V. Arthroscopic hip preservation surgery: Current concepts and perspective. Bone Joint J.

2013;95-B:10-19.● Clohisy JC, Knaus ER, Hunt DM, et al. Clinical Presentation of patients with symptomatic anterior hip impingement. Clin Orthop

Relat Res. 2009;467:638-644. ● 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;5(1):1–8.● Enseki K, Harris-Hayes M, White DM, et al. Nonarthritic hip joint pain. J Orthop Sports Phys Ther. 2014;44(6):A1-A32.

● Fadul DA, Carrino JA. Imaging of femoroacetabular impingement. J Bone Joint Surg Am. 2009;91(suppl 1):138-143.● Hammoud, S. et al. The recognition and evaluation of patterns of compensatory injuries in patients with mechanical hip pain.

Sports health. 2014;6:108-118.● Potter HG, Sharon S, Adler RS. Imaging of the hip in athletes. Sports Med and Arthroscopy review. 2002;10:115-122.● Reiman MP, Thorborg K. Clinical Examination and physical assessment of hip-joint related pain in athletes. The International

Journal of Sports Physical Therapy. 2014;9(4):737-750.● Reiman MP, Decary S, Mathew B, et al. Accuracy of clinical and imaging tests for the diagnosis of hip dysplasia and instability: A

systematic review. J Orthop Sports Phys Ther. 2019;49(2):87-97.● Stone AV, Neal WH, Waterman BR, et al. Pre-operative predictors of return to high functional status after hip arthroscopy for

femoroacetabular impingement at 2-year minimum follow up. Ortho J of Sports Med. 2018;6(7)(suppl 4).● Zaltz I, Kelly BT, Hetsroni I, et al. The crossover sign overestimates acetabular retroversion. Clin Orthop Relat Res.

2013;471:2463-2470. ● https://www.martinpetkov.com/your-opportunity/the-hip-joint-structure-movements-and-muscles● https://www.netterimages.com/hip-joint-labeled-multiple-publications-general-anatomy-frank-h-netter-4654.html