Posterior Hip Pain: Hamstrings and Beyond Benjamin G. Domb, M.D. Medical Director, American Hip Institute Director of Orthopedic Surgery Adventist Hinsdale Hospital Thanks to John Redmond, M.D., AHI Comprehensive Hip Fellow Hinsdale Orthopaedics
Posterior Hip Pain Hinsdale Orthopaedics
Differential Diagnosis Intra-articular Extra-articular Spine • FAI • Piriformis • SI Joint • Dysplasia • Hamstring • Spondylosis • Instability • Ischiofemoral • Radiculopathy Impingement • DJD • Troch Bursa • AVN • Gluteus Medius • Ligamentum Teres • Stress Fx • Labral Tear • Sciatic Nerve Hinsdale Orthopaedics
Is it the Hip or Back? • History • Exam • Injections • Imaging Hinsdale Orthopaedics
Diagnostic Algorithm Hinsdale Redmond, Domb, et al, Arthroscopy 2014 Orthopaedics
Common Things are Common • Labral tears o 38% present with buttock pain • FAI o 29% present with buttock pain • DJD • Lumbar radiculopathy Burnett, R.S., et al., Clinical presentation of patients with tears of the acetabular labrum. J Bone Joint Surg Am, 2006. 88 (7): p. 1448-57. Clohisy, J.C., et al., Clinical presentation of patients with symptomatic anterior hip impingement. Clin Orthop Relat Res, 2009. 467 (3): p. 638-44. Hinsdale Orthopaedics
Extra-Articular Posterior Hip Problems • Piriformis Syndrome • Proximal Hamstring Pathology • Sciatic Nerve Entrapment • Ischiofemoral Impingement Hinsdale Orthopaedics
Piriformis Syndrome • Definition: compression of the sciatic nerve by the piriformis muscle • Literature: primarily Eur Spine J (2010) 19:2095–2109 case series and reviews Hinsdale Orthopaedics
Piriformis Syndrome • Clinical Features –Systematic Review of Symptoms from 51 articles - Eur Spine J (2010) 19:2095–2109 o Buttock Pain in 50-95% o Low Back Pain in 14-63% o Aggravation of sciatica by sitting in 39-97% Hinsdale Orthopaedics
Piriformis Syndrome Physical Exam Tests for Piriformis Syndrome Hinsdale Orthopaedics
Piriformis Syndrome • Objective evidence…..lacking • Fishman et al. attempted nerve conduction studies with the hip in the FAIR position • Found a delay in the H reflex in patients with suspected piriformis syndrome compared to controls Hinsdale Orthopaedics
Piriformis Syndrome • Treatment o NSAIDs o Physical Therapy o Coriticosteroid Injection o Botox Injection o Surgical Release Hinsdale Orthopaedics
Proximal Hamstring • Acute Injuries – Avulsions o Biceps Femoris and Semitendinosus • Chronic Tendonopathy o Semimembranosus Cohen. JAAOS 2007 Hinsdale Orthopaedics
Treatment Algorithm Proximal Hamstring Injury MRI Complete tear of 2 Grade III Grade II Grade I muscles or Grade IV&V <2cm >2cm Surgery Conservative Surgery Hinsdale Orthopaedics
Endoscopic Repair of Proximal Hamstring Avulsion Benjamin G Domb, MD; Dror Lindner, M.D.; Kinzie G Sharp, MS, PA-C; Adam Sadik, BS; Michael B Gerhardt, MD Hinsdale Orthopaedics
Endoscopic Transtendinous Repair for Partial-thickness Proximal Hamstring Tendon Tears Timothy J. Jackson, M.D., Anthony Trenga, B.A. Dror Lindner, M.D, M.D.,a Youseff El- Bitar,M.D.,a and Benjamin G Domb, MD Hinsdale Orthopaedics
Sciatic Nerve Entrapment • The sciatic nerve can become entrapped anywhere along its course o Fibrous or muscular entrapment o Vascular compression o Tumors o Scarring from trauma – hamstring rupture Hinsdale Orthopaedics
Sciatic Nerve Entrapment • Symptoms o Buttock Pain o Radicular pain into the foot o Pain with sitting o Paresthesias Hinsdale Orthopaedics
Sciatic Nerve Entrapment • Exam o Active piriformis test positive in 18 of 23 patients (78%) o Seated piriformis stretch 12 of 23 patients (52%) o Straight Leg Raise 4 of 23 patients(17%) Martin et al. KSSTA. 2014 Hinsdale Orthopaedics
Sciatic Nerve Entrapment • Treatment o Variable – depending on the site of pathology o Sciatic Neurolysis o Martin et al. Arthroscopy 2010 35 patients treated with arthroscopic neurolysis mHHS at avg 12 months 54 to 78 83% of patients had resolution of buttock pain Hinsdale Orthopaedics
Ischiofemoral Impingment • Definition: Abnormal contact between the lesser trochanter and the ischium Hinsdale Orthopaedics
Ischiofemoral Impingement • Symptoms: • Physical Exam: o Groin pain o Painful hip external rotation in extension o Buttock pain o Tenderness along the o Typically slow onset posterior trochanter o Clunking during gait Safran et al. KSSTA. 2014 Hinsdale Orthopaedics
Ischiofemoral Impingement • MRI o Decreased space between the ischium and lesser trocanter o Edema in the quadratus femoris o Torrani et al. – Patients with quadratus edema compared to controls – 13 vs 23 mm. (AJR 2009) Hinsdale Orthopaedics
Ischiofemoral Impingement • Treatment o NSAIDs o PT o Surgical Lesser trochanter excision Safran et al. KSSTA. 2014 Hinsdale Orthopaedics
Summary • Many causes of posterior hip pain • Use diagnostic algorithm • Intra- and extra-articular causes have surgical treatment options Hinsdale Orthopaedics
Thank You www.AmericanHipInstitute.org Benjamin G. Domb, M.D. Medical Director, American Hip Institute Director of Orthopedic Surgery Adventist Hinsdale Hospital Hinsdale Orthopaedics
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