Zhang Hip Common Problems in adults and kids...Hip Labral Tear- can be acute event 28 11/20/2017 15 FAI- Common symptoms Common Symptoms •Anterior groin and in c-shaped band •Worse

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What’s Hip:Common Hip Problems and Kids and Adults

Alan Zhang MDAssistant ProfessorSports Medicine and Hip ArthroscopyUCSF Department of Orthopaedic Surgery

I have no relevant disclosures.

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Most Common Hip Pathologies

STAIRS

Strain

Trochanteric Pathology

Arthritis (and Avulsion)

Impingement

Referred pain

Stress Fracture

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Big 3- Questions to Ask

Chronicity- When did it happen?

Mechanism- How did you injure it?

Location- Where is the pain?

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Chronicity

Acute

Chronic

• Overuse

• Repetitive microtrauma

• Degenerative

• No specific injury

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Mechanism of Injury

Contact

Non-contact

• Twisting

• Squatting

• Flexion/extension

• “Pop”

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Location, Location, Location

Anterior/groin

• FAI

• Arthritis

• Flexor strain

Lateral/thigh

• Trochanteric pathology

• Snapping hip

Buttock/posterior

• Low back/sciatic nerve

• Referred pain

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Anatomy

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Intra-articular Anatomy

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Anatomy

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Muscle insertions

Strain (Muscle Strain)

Most common injury in hip and pelvis

• All ages

Most common location at muscle-tendon junction

Most prone to strain if cross 2 joints (hip and knee)

• Hip flexors (anterior)

‒ Rectus femoris

‒ Sartorius

‒ Iliopsoas

• Proximal Hamstrings (posterior)

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Muscle Strain Treatment

Non-operative treatment

Rest, Ice, Compression, NSAIDs

Gentle range of motion exercises when pain improves

Strengthening once full ROM regained

Return to play (RTP): 1-3 weeks

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Trochanteric Pathologies

Trochanteric bursitis

IT Band Syndrome

Gluteus tear

All have lateral sided hip pain

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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

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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

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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

Trendelenburg sign

Treatment

• PT, CSI

• Endoscopic gluteus repair is an option

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Physical Exam

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Hip Abduction Testing

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Gluteus Medius Tear

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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

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Clinical Presentation

Physical Exam

• Decreased range of motion

• Pain in groin, lateral and posterior

• Crepitus with ROM

• Altered gait

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Radiographic Findings

AP Pelvis

• Joint space narrowing

• Subchondralsclerosis

• Osteophytes

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Treatment

Conservative

• Physical Therapy

‒ Gluteal and core strengthening

• Cortisone injection

‒ Ultrasound or fluoroscopic guidance

Operative treatment

• Total hip arthroplasty

‒ Anterior, anterolateral, posterior approach

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Avulsions (Apophyseal Avulsion)

Occurs in Children

Usually non-contact, quick acceleration mechanism

Avulsion of bone at tendon attachment

• ASIS- sartorius

• AIIS- rectus

• Ischial tuberosity- hamstring

• Lesser trochanter- iliopsoas

Treatment- rest, ice, protected weightbearing (crutches) until pain improved, ROM and strengthening, rarely surgery

RTP: 2-3 months

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Apophyseal Avulsions

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ASIS AIIS Lesser Troch

Impingement

Femoroacetabular Impingement (FAI)

• Abnormal bony anatomy that forms during development

Age group 15 to 45 years old

More commonly chronic injury (can be acute)

Can lead to intra-articular injury to labrum and cartilage

Can lead to early arthritis

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FAI

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

Hip Labral Tear- can be acute event

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FAI- Common symptoms

Common Symptoms

• Anterior groin and in c-shaped band

• Worse with prolonged sitting

• Activity related (walking, running, jumping, squats)

Physical Exam

• Pain with Flexion Adduction Internal Rotation (FADIR)

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Imaging

Radiographs (AP pelvis, Dunn Lateral)

MRI/MRA

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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

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FAI and Arthritis

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• For patients <50 years old with hip arthritis• 45% due to FAI, 45% hip dysplasia, 10% trauma/other

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Treatment

Conservative treatment

• Rest

• PT- core strengthening, gluteal strengthening

• CSI

Surgical treatment

• Hip Arthroscopy

‒ Labral repair

‒ Osteochondroplasty

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Surgical Treatment- Hip Arthroscopy

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Cam DecompressionPre-op Post-op

Alan Zhang, MDUCSF Hip Arthroscopy

Pincer Decompression

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Labral Repair

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Outcomes

Byrd et al 2011

200 athletes with 2 year follow up after hip arthroscopy

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

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Does FAI Surgery Prevent Arthritis?

Quantitative MRI to assess for early cartilage injury in hip

NIH funded study at UCSF- actively recruiting patients

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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

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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

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Stress Fracture

Acute on chronic injury (overtraining)

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

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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

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Strain

• Hip flexor/Proximal Hamstrings

Trochanteric Pathology

• Bursitis, IT Band, gluteus tear

Arthritis/Avulsion

• Arthritis is older adults, avulsion in kids

Impingement

• FAI, Labral tears

Referred pain

• Lumbar spine/knee

Stress Fracture

• Female athlete triad

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STAIRS

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Thank you

Alan Zhang, MD

[email protected]

415-353-4843

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References

1. 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.

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