Whats Hip: Common Hip Problems and Kids and Adults Alan Zhang MD - PDF document

11/20/2017 What’s Hip: Common Hip Problems and Kids and Adults Alan Zhang MD Assistant Professor Sports Medicine and Hip Arthroscopy UCSF Department of Orthopaedic Surgery I have no relevant disclosures. 2 1

11/20/2017 Most Common Hip Pathologies  STAIRS  S train  T rochanteric Pathology  A rthritis (and Avulsion)  I mpingement  R eferred pain  S tress Fracture 3 Big 3- Questions to Ask  Chronicity- When did it happen?  Mechanism- How did you injure it?  Location- Where is the pain? 4 2

11/20/2017 Chronicity  Acute  Chronic • Overuse • Repetitive microtrauma • Degenerative • No specific injury 5 Mechanism of Injury  Contact  Non-contact • Twisting • Squatting • Flexion/extension • “Pop” 6 3

11/20/2017 Location, Location, Location  Anterior/groin • FAI • Arthritis • Flexor strain  Lateral/thigh • Trochanteric pathology • Snapping hip  Buttock/posterior • Low back/sciatic nerve • Referred pain 7 Anatomy Intra-articular Anatomy 8 4

11/20/2017 Anatomy Muscle insertions 9 11/20/2017 S train (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) 10 11/20/2017 5

11/20/2017 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 11 11/20/2017 T rochanteric Pathologies  Trochanteric bursitis  IT Band Syndrome  Gluteus tear  All have lateral sided hip pain 12 6

11/20/2017 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 13 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 14 7

11/20/2017 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 15 Physical Exam Hip Abduction Testing 16 8

11/20/2017 Gluteus Medius Tear 9

11/20/2017 A rthritis 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 20 10

11/20/2017 Clinical Presentation  Physical Exam • Decreased range of motion • Pain in groin, lateral and posterior • Crepitus with ROM • Altered gait 21 Radiographic Findings  AP Pelvis • Joint space narrowing • Subchondral sclerosis • Osteophytes 22 11

11/20/2017 Treatment  Conservative • Physical Therapy ‒ Gluteal and core strengthening • Cortisone injection ‒ Ultrasound or fluoroscopic guidance  Operative treatment • Total hip arthroplasty ‒ Anterior, anterolateral, posterior approach 23 A vulsions (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 24 11/20/2017 12

11/20/2017 Apophyseal Avulsions Lesser Troch ASIS AIIS 25 11/20/2017 I mpingement  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 26 13

11/20/2017 FAI • Cam-Type- femoral head neck asphericity • Pincer Type- acetabulum overcoverage • Mixed Type- both Cam and Pincer 27 Hip Labral Tear- can be acute event 28 14

11/20/2017 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) 29 Imaging  Radiographs (AP pelvis, Dunn Lateral)  MRI/MRA 30 15

11/20/2017 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 31 FAI and Arthritis • For patients <50 years old with hip arthritis • 45% due to FAI, 45% hip dysplasia, 10% trauma/other 32 16

11/20/2017 Treatment  Conservative treatment • Rest • PT- core strengthening, gluteal strengthening • CSI  Surgical treatment • Hip Arthroscopy ‒ Labral repair ‒ Osteochondroplasty 33 Surgical Treatment- Hip Arthroscopy 34 17

11/20/2017 Cam Decompression Pre-op Post-op Alan Zhang, MD UCSF Hip Arthroscopy Pincer Decompression 36 11/20/2017 18

11/20/2017 Labral Repair 37 Outcomes  Byrd et al 2011  200 athletes with 2 year follow up after hip arthroscopy  90% returned to sport (95% pro, 85% collegiate) 38 19

11/20/2017 Does FAI Surgery Prevent Arthritis?  Quantitative MRI to assess for early cartilage injury in hip  NIH funded study at UCSF- actively recruiting patients 39 R eferred 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 40 20

11/20/2017 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 41 S tress 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 42 21

11/20/2017 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 43 STAIRS  S train • Hip flexor/Proximal Hamstrings  T rochanteric Pathology • Bursitis, IT Band, gluteus tear  A rthritis/Avulsion • Arthritis is older adults, avulsion in kids  I mpingement • FAI, Labral tears  R eferred pain • Lumbar spine/knee  S tress Fracture • Female athlete triad 44 22

11/20/2017 Thank you  Alan Zhang, MD  alan.zhang@ucsf.edu  415-353-4843 45 11/20/2017 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. 46 11/20/2017 23