Understanding the diagnosis of hip problems: When to refer to the - - PowerPoint PPT Presentation
Understanding the diagnosis of hip problems: When to refer to the surgeon and when to hold on! Dirk Kokmeyer, PT, DPT, SCS, COMT Director of Rehabilitation and Performance Maine Medical Partners, Orthopedics and Sports Medicine Portland, Maine
Understanding the diagnosis of hip problems: When to refer to the surgeon and when to hold on!
Director of Rehabilitation and Performance
Maine Medical Partners, Orthopedics and Sports Medicine Portland, Maine dkokmeyer@mmc.org
@DirkKokmeyer
Dirk Kokmeyer, PT, DPT, SCS, COMT
clinical pathways
EBM
Hip Pain Hip Stiffness Hip/LE Dysfunction
Patient Values Evidence Clinical Expertise Patient Values Evidence Clinical Expertise
Nerve Entrapment
FAI/Labral Tear
Chondral issues
Athletic Pubalgia Soft tissue disorders
Referred pain
Sports Perf/PT Sports Med PCP Surgeon
Dunn, JSES, 2016 NEER AWARD Mohamad, J of Rheumatology, 2002 Nicholas, PTJ, 2011 Puendetura, JOSPT, 2012
Irritability Classification
High Moderate Low
High Pain (≥7/10) Consistent night or rest pain High disability/low function
Pain prior to end ROM AROM less than PROM secondary to pain Moderate Pain (4-6/10) Intermittent night or rest pain Moderate disability/function
Pain at end ROM AROM similar to PROM Low Pain (≤3/10) No resting or night pain Low disability/high function
Minimal pain at end ROM with overpressure AROM same as PROM PROM, modalities, pain reduction, activity modification Referral sooner if no change in symptoms PROM, modalities, pain reduction, activity modification Referral in 4-8 weeks if no change in symptoms Functional activities, strengthening as tolerated, activity modification Referral in 6-8 weeks if surgical indications
Modified from:
Kirby et al, MSK Imaging, 2010: 14% of hip fractures missed by radiographs Dominguez, Acad Emerg Med, 2005: 4.4% hip fractures missed
(i.e. hip fracture)
for hip fractures
Case example of gentleman referred with knee pain and hip OA
Altman et al, Arthritis and Rheumatism, 1991
Hip IR < 15º
Hip Flex < 115º Morning Stiffness >60 min
Age >50 yrs
Sensitivity 86%, Specificity 75%
HIP PAIN +
Joint Space narrowing
Femoral/ Acetabular Osteophytes
Sensitivity 91%, Specificity 89%
Altman et al, Arthritis and Rheumatism, 1991 HIP PAIN +
Beumer et al, BJSM, 2016 SR with meta-analysis
benefit with pain/WOMAC
benefit
low to high surgical risk - failed “correct” conservative mgmt
limitation - failed conservative mgmt
WRT pain
“sports hernia”
c/c: severe groin, lower abdominal or pubic region, induced by exertion. Definition: weakness of the posterior inguinal wall.
Involves injury to the (Meyer, ann of surg, 2008):
Cluster of findings:
deep groin, abdominal, pubic pain
sport specific movements: running, kicking, cutting. 3.TTP: pubic symphysis, conjoined tendon, int/ext
insertions 4.Pain with resisted hip adduction and/or hip flexion 5.Pain with resisted curl-up
algorithm to treatment Kachingwe and Grech, JOSPT, 2008
Indication for PT based on: RTP> 4 mo & + hx of “rip”
not high-performance athlete Surgery indicated if: + hx of “rip”, RTP< 4 mo
}1997-2006: 23,806 injuries }738 hip injuries
}32% (12/38) had AP surgery also
}39% (15/38) had complete
Burnett et al, JBJS, 2006
before dx made
Reiman et al, BJSM, 2013
Hx:
+LR 6.67, r=0.79 for labral tears
96-100%)
Special Tests: Thomas Test, FADDIR (and derivatives) =
Surgeon 1:
Skeletally immature Female:
soft tissue Young male:
but not afraid to fix a big CAM lesion quickly. Young female:
pelvic control + glute firing
injection = return to PT >35 female
benefit!
Surgeon 2:
Skeletally immature:
will treat more aggressively with surgery if + MRI 18-30
aggressively with surgery and see sooner if PT
Surgeon 3:
“I don’t believe in paternalism; it’s up to the PT” + Scour/FADIR, failed conservative mgmt, pt is miserable = refer!
Surgeon 4:
Skeletally immature Female:
growth plate closed
Young male:
with radiographic evidence of FAI Young female:
>40 female
>40 male
sooner
Surgeon 5:
Skeletally immature:
hip pain, refer quickly for imaging and MD eval (r/o SCFE).
Skeletally mature:
Referral OK if no improvement noted. 40+
improvement
increase tissue irritability
Labral tear 69% Chondral defect 24% Ligamentum teres tear 2.2% Labral/Paralabral cyst 13% Acetabular bone edema 11% Fibrocystic changes of the femoral head/neck junction 22% Rim fracture 11% Subchondral cysts 16% Osseus bump on the femoral neck 20%
Emara, JOS, 2011
Yazbek, JOST, 2011
Mansell, BMC MSK dis, 2016
Griffin, BMJ, 2016
Wright, J sci med sport, 2017
hesitation.
treatment of stabilization exercises, selective stretching, pelvic control in CKC activities
seeing and ortho surgeon
bad, REALLY go bad.
rehab is easy with this population (less complications)
Maine Medical Partners Orthopedic and Sports Medicine