Hip Pain Mark Stovak, MD Family Medicine Winter Symposium Kyle Goerl, MD December 5, 2014

HipPain

• Porter • Stovak – StressFractures HipPain – Apophysitis – Bursitis – DJD – Tendinopathy – HipImpingement – SnappingHip MarkStovakMD – Labral tear AndrewPorterDO – SportsHernia

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Apophysitis

• Apophysis – siteof • Clinicaldiagnosisbased tendonattachment onlocationofpaininan priortoskeletal adolescent maturity • Hurtstostretchor • Apophysitis – contract inflammationfrom • XRsusedtoconfirm repetitivemicrotrauma wideningtohelpwith fromtractionbytendon prognosis&RTPmore • Avulsion– traumatic thandiagnosis contractionoftendon onapophysis

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1 Hip Pain Mark Stovak, MD Family Medicine Winter Symposium Kyle Goerl, MD December 5, 2014

Apophyses HipApophyses

• IliacCrest:abdominal (internal/externaloblique andtransversus abdominus) • ASIS:sartorius • AIIS:rectusfemoris • GreaterTrochanter:glut med/min • LesserTrochanter:iliopsoas • Ischial Tuberosity: hamstring • Inferiorpubicramus: adductors

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PelvicAvulsions

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2 Hip Pain Mark Stovak, MD Family Medicine Winter Symposium Kyle Goerl, MD December 5, 2014

Treatment DJD/Osteoarthritis

• Avoidvigorousstretching • Relative rest • HamstringAvulsions– • RapidlyProgressive • Crutchesifneeded trendtosurgicallyfixnow • LossofIR>ER • NSAIDS/Prednisone? • Therestshouldbe treatedconservatively • RTPaslongasnopainto • Painwithpassiveend stretch,goodstrength, • Surgeryifpaindoesnot ROM resolve,cosmeticreason, andpassafunctional • Anteriorhip/groinpain progressionwithout or>2cm limping • ManualTherapy, (notlateralhip,posterior • Riskisavulsion Tenotomy,Autologous hip,orbuttockpain) BloodInjection(ABI)or PlateletRichPlasma(PRP) • Painmayradiatedown priortosurgery thigh

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HipDJD

• JointSpaceNarrowing • Cysts • Sclerosis • Osteophytes

• Coxa Profunda • Protrusio Acetabulae

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3 Hip Pain Mark Stovak, MD Family Medicine Winter Symposium Kyle Goerl, MD December 5, 2014

HipDJDTreatment

• NWBExercise–thebest • TheRest – Acetominophen – NSAIDS – Prednisone – Injections–Steroid,Viscosupplementation,ABI,PRP NotHelpful – Glucosamine/Chondroitin – PhysicalTherapy

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HipImpingement FADIRvs FABER • AnatomicalIssue • Incongruityleadstoearly labral tearsandchondral injury • Theoretically– fixing theseissueswillprevent earlyDJD • Painwithactivity • ANTERIORgroinpain • PainwithFADIRorIRlog rollorscourtest

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4 Hip Pain Mark Stovak, MD Family Medicine Winter Symposium Kyle Goerl, MD December 5, 2014

Camvs PincerImpingement(orboth) PLAINXR

• Cam • Pincer • SupinePelvisAP – HeadͲneckjunction – Acetabular retroversion • FrogLegLateral offsetissue – Coxa Profunda • CrossTableLateralwith – Physis injury – Protrusio Acetabulae legin15degreesIR – NearͲSCFE • Dunnviews–45&90 • Crossoversign degrees • Femoralneckbump • Pistolgripdeformity

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AP AP– Tiltvs Arch

• Wellcenteredpelviswiththe distancefromthecoccyxtotheto pubicsymphosis–1cm • OR • Sacrococcygealjointtopubic symphosis3Ͳ5cm • Tiltofpelvisunderestimatesthe crossover(Retroversion) • Archcanoverestimatecrossover • Rotationalsomatters – Torightwilloverestimateright retroversion&underestimate left

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5 Hip Pain Mark Stovak, MD Family Medicine Winter Symposium Kyle Goerl, MD December 5, 2014

FrogLegLateral/XͲTableLateral PistolGripDeformity

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Crossover Os Acetabuli

• Anteriorrimover • Considerednormal posteriorrim variantsofsecondary (retroversion) ossificationof acetabulum • Nowconsidered suspiciousfor underlyinglabral tear

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6 Hip Pain Mark Stovak, MD Family Medicine Winter Symposium Kyle Goerl, MD December 5, 2014

SynovialHerniationPit MRI(MRA)

• Normalvariant5% • ScreeningPelvis–R/OAVN,stressfx.,tendon population avulsion,tumor(IVcontrast),osteitis pubis • Nowconsideredc/wFAI • MRAunilateralhip–moresensitive90%vs 30%for intraͲarticularpathology–labraltears,cartilage lesions • Anesthetichelpfulclinicallyduringinjection • T2fatsats • 1.5Teslamagnetorgreater • Ligamentum teres tearsstillundetected(3rd most commoninathletes)

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Labral Tears Labral Tear

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7 Hip Pain Mark Stovak, MD Family Medicine Winter Symposium Kyle Goerl, MD December 5, 2014

Doesthepainmatchtheimaging? ImpingementTreatment

• Highpercentageofasymptomaticathletes • PainbutNoIntraͲarticular • PainandChondral lesionor haveradiographicchangesofcam&pincer Pathology Labral tear – NSAIDS – ArthroscopicBony impingement – Prednisone Debridement&Labral • Manylabral tearsareasymptomatic – SteroidInjection Repair • Thustheanestheticinjection – Coxa Profunda &Protrusio Acetabulae notamenable toarthroscopicsurgery

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SportsHernia(AthleticPubalgia, WhatItIsNot(butoftengetslumped Gilmore’sGroin) together) • TrashͲBagDiagnosis • DDX • PreͲhernia • Weakening/thinningofthe – Pubicramistressfracture anteriorwalloftheinguinal canal – Osteitis pubis • Hurtsinthegroinwith – Tendinopathy oftheadductorsorrectus activity&mayinvolve paresthesias from abdominus ilioinguinal orgenitofemoral – Lateralfemoralcutaneousnerveentrapment nerveirritation • Resolveswithrest – Iliopsoas bursitis • Painfor6monthswith – SnappingHipSyndrome failedtherapy

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8 Hip Pain Mark Stovak, MD Family Medicine Winter Symposium Kyle Goerl, MD December 5, 2014

Imaging Treatment

• XR–Normal • RelativeRest&PhysicalTherapyfocusedon • CT–Normal thesuspecteddiagnosis • MRI/MRA–Normal • Ifnotbetter&trulythecorrectdiagnosis– • BoneScanͲ Normal referralforsurgery • • U/SͲ ?Abnormality NoSurgeonsinWichita

• ClinicalDiagnosis

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9 Hip Pain Mark Stovak, MD Family Medicine Winter Symposium Kyle Goerl, MD December 5, 2014

Hip Pain Stress Fractures

1st Half 2nd Half • Stress Fractures in general – Apophysitis – Stress Fractures • Specific treatment recommendations – DJD – Bursitis – Hip Impingement – Tendinopathy – Femoral Neck – Labral tear – Snapping Hip – Femoral Shaft – Sports Hernia – Sacrum

– Ilium

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Stress Fractures Stress Fractures

• Occur when osteoclastic activity overwhelms osteoblastic activity • Physical exam • Bone injury unfolds over a continuum of time without intervention – Tests to perform in the area of interest are palpation, the tuning fork test, the fulcrum test, & the hop test

Normal Bone → Stress Reaction → Stress Fracture → Fracture • Palpation

– Pain over affected bone with palpation • Result from excessive stress on normal bone from overactivity • Fulcrum Test • Result from normal stress on a bone that is deficient (osteoporotic, – Pain in fracture site while applying a bending force (e.g., over exam poor nutrition, or in female athlete triad) table) to distal extremity while proximal extremity is kept relatively • Common injuries in athletes & people who are active immobilized • Running sports account for 69% of stress fractures • Hop Test • Suspect in someone who is active: – Hopping 10 times on affected leg reproduces pain at fracture site – + bone pain • Tuning Fork Test – + performs repetitive activities with limited rest or recent increase in – Vibrating tuning fork over fracture site results in pain at site activity

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10 Hip Pain Mark Stovak, MD Family Medicine Winter Symposium Kyle Goerl, MD December 5, 2014

Stress Fractures Stress Fractures – Prevention

• • Distribute loading forces on the bone with cross training & Imaging biomechanical adjustments – If a stress fracture is suspected, x-rays should be – Orthotics, proper shoes, stretches, strengthening, running mechanics) obtained – Consume sufficient calories to maintain adequate energy availability • Takes 2 to 3 weeks for signs of stress fracture (i.e., periosteal – Ensure appropriate intake of calcium and vitamin D. reaction, callus formation, fracture line) to show up on x-ray • A study by Lappe of female Navy recruits showed reductions in stress fractures in those consuming 2000 mg of Calcium & 800 IU • Often stress fractures do not show up on x-rays vitamin D daily (supplement or diet) – If x-rays are negative & diagnosis is needed to help • Tobacco should be avoided guide care & return to activity a bone scan or MRI • Women of child bearing age should try to maintain regular menses should be obtained by consuming adequate calories & avoiding a negative energy balance – Bone scan can stay positive for up to 18 months • Clinical progress should not be monitored with a bone scan

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Stress Fractures – Treatment Stress Fractures – Treatment

• Nutrition, medication, & biomechanical recommendations • Nutrition • Begin a rehabilitation program when tolerated – Optimizing energy availability in diet – Ensuring adequate calcium & vitamin D intake • Stretch & strengthen supporting structures – Avoidance of tobacco exposure • Medication • Start a gradual increase in activity when pain – Acetaminophen PRN – Avoidance of NSAIDs as they can slow bone healing free • Biomechanical – Offload the affected bone – Reduce activity to pain-free functioning & pain-free cross-training – Crutches may be needed to offload the injured area even more than a walking boot/cast or steal shank – May require NWB • Goal = pain-free ambulation during the initial tx

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11 Hip Pain Mark Stovak, MD Family Medicine Winter Symposium Kyle Goerl, MD December 5, 2014

Stress Fractures Stress Fractures High Risk vs Low Risk Low Risk vs High Risk • Because of their propensity for delayed healing & • Biomechanical forces along the bone with nonunion, certain stress fractures are considered activity are used to classify femur neck stress high risk, necessitate prompt treatment, & may fractures as either compression-sided or ultimately require surgical fixation tension-sided – Femoral Neck – When running, the femoral neck compresses • Low-risk stress fractures have a lower incidence inferior medially so the inferior medial aspect of of delayed healing & nonunion the femoral neck is considered compression sided – Femoral Shaft • These variable forces on different parts of the – Sacrum bone affect the potential for delayed healing – Ilium & nonunion

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Stress Fractures – Specific Tx Stress Fractures – Specific Tx

• LOW-RISK STRESS FRACTURE INITIAL TREATMENT • HIGH-RISK STRESS FRACTURE INITIAL – Sacrum TREATMENT • WBAT 6–12 weeks – Femoral neck (compression side) – Ilium • IF STABLE AND NONDISPLACED • WBAT 6–12 weeks • NWB 6–8 weeks → PWB → FWB over next 6–8 weeks – Femoral shaft • WBAT 6–8 weeks – Femoral Neck (Tension Sided) • NWB & Orthopaedic Surgical Referral

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12 Hip Pain Mark Stovak, MD Family Medicine Winter Symposium Kyle Goerl, MD December 5, 2014

Femoral Neck Compression Sided Tendinopathy Stress Fracture • Tendinopathies – Tendonitis – Tendinosis • Tendinitis – Painful overuse tendon conditions – Inflammation is present • Tendinosis – Most common pathology in chronic painful tendons – Occurs after repetitive injuries to a tendon that results in intertendinous scarring, disorganization of tendon fibers & degeneration. – NO inflammatory component • Bottom Line – Early on in a tendon injury, there is inflammation resulting in tendinitis, but after about 6 weeks this generally evolves into tendinosis

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Normal Tendon Tendinosis

• Type-I collagen bundles packed tightly along the • Collagen fiber disorientation tendon axis with sparse occurs with dense populations fibroblasts between the of fibroblasts & scattered collagen rows vascular hyperplasia (angiofibroblastic hyperplasia)

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13 Hip Pain Mark Stovak, MD Family Medicine Winter Symposium Kyle Goerl, MD December 5, 2014

Tendinopathy – Treatment Tendinopathy – Treatment Tendinosis • Tendonitis • Healing is facilitated by creating an inflammatory – STOP the inflammation response • To create inflammation – NSAIDs (oral or topical) – Eccentric strengthening – Rest – Deep soft tissue massage with tools (e.g., gua sha, – Early activity modification Graston®, or ASTYM®)

– PT – Nitroglycerin patches (Nitro-Dur)1 – Treatment may prevent the development of – MSK US percutaneous needle tenotomy(with or without injection of autologous blood, prolotherapy, tendinosis or platelet-rich plasma)

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ASTYM Tools Tendinosis Treatment

• Avoid NSAIDs – NSAIDs will prevent an inflammatory response • Concept of tendinosis diagnosis & treatment can be utilized for tendons throughout hip & pelvis – Most commonly applied to the Iliotibial (IT) band, Piriformis, Gluteus Medius, Iliopsoas & Hamstrings

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14 Hip Pain Mark Stovak, MD Family Medicine Winter Symposium Kyle Goerl, MD December 5, 2014

Bursitis Pelvic Bursae – most common sites

• 13 consistent bursae around the hip region • May co-exist with other hip pain etiologies such as tendinosis or tendonitis & may be difficult to differentiate

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Trochanteric Bursitis Ober Test

• Description & History – Common to see associated with IT Band Syndrome

– More common in females – Common in runners – Lateral hip pain, usually from overuse • Physical – TTP directly over bursa on greater trochanter – Ober test is positive if they have IT Band Tightness

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15 Hip Pain Mark Stovak, MD Family Medicine Winter Symposium Kyle Goerl, MD December 5, 2014

Trochanteric Bursitis Trochanteric Bursitis

• Imaging • Treatment – NSAID’s – X-rays to evaluate hip & pelvis bones • Oral &/or topical • Rule out calcifications • Greater Trochanteric Bursa injection with Anesthetic & Steroid • Rule out other causes of hip pain – Can use MSK US to improve accuracy – Lidocaine 1% without epi & 80 mg Depomedrol with 25 gauge 3.5 inch • Advanced imaging only for refractory cases needle • Physical Therapy – Stretching of IT band, core strengthening, pelvic stabilization, iontophoresis/phonophoresis – Eccentric strengthening of the hip abductors & ASTYM for IT band if concomitant IT Band tendinosis – Activity modification • Cross training in non-painful activities

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Iliopsoas Bursitis Iliopsoas Bursitis – Physical

• Description & History • Localized TTP at region – Anterior Hip Pain &/or groin pain of iliopsoas bursa – Largest Bursa in the body • Pain with resisted active hip flexion – Usually associated with iliopsoas tendonitis/tendinosis • No significant pain with passive hip flexion & – Overuse injury internal rotation ROM

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16 Hip Pain Mark Stovak, MD Family Medicine Winter Symposium Kyle Goerl, MD December 5, 2014

Iliopsoas Bursitis Iliopsoas Bursitis

• Imaging • Treatment – X-rays – NSAID’s • Important to evaluate the underlying bones of the hip • Oral &/or topical & pelvis • MSK US Guided Iliopsoas Bursa & Tendon Sheath Injection • AP Pelvis, Cross Table Lateral or Frog Leg Lateral Views • Physical Therapy • Dunn views if concerned for FAI (Femoracetabular – Stretching of IT band, core strengthening, pelvic stabilization, & Impingement) &/or labral tear iontophoresis/phonophoresis • MSK US – Eccentric strengthening & ASTYM if concomitant Hip Flexor &/or • Advanced imaging (MRI, CT Scan, Bone Scan, SPECT adductor tendinosis Scan) if clinically indicated is used to rule out other – Activity modification etiologies • Cross training in non-painful activities

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Ischial Bursitis Ischial Bursitis

• Description & History • Imaging – Adjacent to hamstring tendon attachment onto the • X-rays ischial tuberosity – Important to evaluate the underlying bones of the hip & pelvis – Can be difficult to differentiate between hamstring – AP Pelvis, Cross Table Lateral or Frog Leg Lateral Views etiology – MSK US – Localized pain to the area – Advanced imaging (MRI, CT Scan, Bone Scan, SPECT Scan) if • Physical clinically indicated is used to rule out other etiologies – TTP over ischium – Minimal to no pain with stretching of the hamstrings – Minimal to no pain with resisted knee flexion

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17 Hip Pain Mark Stovak, MD Family Medicine Winter Symposium Kyle Goerl, MD December 5, 2014

Ischial Bursitis Snapping Hip

• Treatment • 2 most common causes – NSAID’s – Snapping IT Band • Oral &/or topical – Snapping Iliopsoas Tendon • MSK US Guided Ischial Bursa Injection • Physical Therapy – Stretching of Hamstrings, core strengthening, pelvic stabilization, & iontophoresis/phonophoresis – Eccentric strengthening & ASTYM for hamstrings if concomitant hamstring tendinosis – Activity modification • Cross training in non-painful activities

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Snapping IT Band Tendon Snapping IT Band Tendon

• Description & History • Imaging – Snapping may occur after injury or trauma but most commonly develops without injury – Used to rule out other causes of hip pain if – Snapping occurs when the tensor fascia lata & gluteus clinically indicated maximus flip across the greater trochanter – Patients describe a snap & +/- feeling of instability – Start with X-rays if suspected bone involvement or – Snapping is not always painful if pain has been present for extended amount of • Physical time (~4 weeks) – Have patient re-create the snapping • MSK US – Lateral position with affected hip up, passively extend & • hip to try & reproduce the snapping Advanced imaging (MRI, CT Scan, Bone Scan, SPECT – Ober test for IT band tightness Scan)

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18 Hip Pain Mark Stovak, MD Family Medicine Winter Symposium Kyle Goerl, MD December 5, 2014

Snapping IT Band Tendon Snapping Iliopsoas Tendon

• Treatment • Description & History – Physical Therapy • Main treatment – Usually insidious onset • Stretching of IT band, core strengthening, pelvic stabilization, eccentric strengthening of the hip abductors, iontophoresis/phonophoresis – Can be after injury or trauma • ASTYM for IT Band – • Soft tissue release techniques of IT Band Snapping occurs as the tendon flips across the – ART, IT band release, myofascial release anterior femoral head & capsule & pectineal – NSAID’s eminence – Greater Trochanteric Bursa Injection – Activity modification • Physical • Cross training in non-painful activities – Re-create snapping • Refractory cases – other txs to consider – Percutaneous needle tenotomy +/- ABI of IT Band • Supine position – Surgical release of IT band • Hip initially placed in flexion, abduction, & external rotation & then moved into extension with internal rotation

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Snapping Iliopsoas Tendon Snapping Iliopsoas Tendon

• Imaging – Used to rule out other causes of hip pain if clinically indicated – Start with X-rays if suspected bone involvement or if pain has been present for extended amount of time (~4 weeks) • MSK US • Advanced imaging (MRI, CT Scan, Bone Scan, SPECT Scan)

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19 Hip Pain Mark Stovak, MD Family Medicine Winter Symposium Kyle Goerl, MD December 5, 2014

Snapping Iliopsoas Tendon References

• Treatment • Almekinders LC. Anti-inflammatory treatment of – Physical Therapy • Main treatment muscular injuries in sports. Sports Med • Stretching of iliopsoas, core strengthening, pelvic stabilization, eccentric 1993;15:139–45. strengthening of the hip flexors & adductors, iontophoresis/phonophoresis • ASTYM for iliopsoas tendon • Byrd, JW. Pelvis, Hip, & Thigh Injuries. In: • Soft tissue release techniques of Iliopsoas tendon Madden C, Patukian M, Young C, McCarty E, – ART, Iliopsoas tendon release, myofascial release – NSAID’s editors. Netter’s Sports Medicine. Philadelphia: – MSK US Guided Iliopsoas Tendon sheath & bursa injection Elsevier; 2010. pp 404-416. – Activity modification • Cross training in non-painful activities • Lappe J, Cullen D, Haynatzki G, et al. Calcium and • Refractory cases – other txs to consider vitamin D supplementation decreases incidence – Percutaneous needle tenotomy +/- ABI of Iliopsoas Tendon of stress fractures in female navy recruits. J Bone – Surgical release of Iliopsoas tendon Miner Res 2008;23:741–9.

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Questions?

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