hip pathology w mccormick 2017 mccormickortho.com overview

• classification • common hip pathologies • FAI • GT pain • snapping • workup • treatments • sample cases • rehabilitation • outcomes/complications hip pathology classification

• V – Vascular • mechanical • I – Inflammatory • congenital • N – Neoplastic • dysplasia • FAI • D – Degenerative / Deficiency • acquired • I – Idiopathic • trauma • FAI • C – Congenital • A – Autoimmune • non mechanical • T – Traumatic • immune • E – Endocrine • infection • vascular (AVN) hip pathology classification - anatomic

• groin • adductor muscle • anterior acetabular/labral • fascial disruption • flexion crease • acetabular/labral • iliopsoas tendon • C-sign • lateral acetabular/labral • GT • abductor tendon • IT band (snapping) • buttock • posterior acetabular/labral • sciatic mechanical articular hip problems

• single event trauma • dislocations/fractures/labral tears • think shoulder dislocation • cumulative trauma • labral tear • usually in setting of too much/too little bone • cartilage injury • point loading and shear mechanical non articular hip problems

• ischiofemoral impingement • sciatic entrapment • tendon tears • abductor • hamstring • fascial disruption (aka sports hernia etc) onion layers

• limping • pain behavior • muscle activation pattern changes • GT pain syndrome • narcotic use • mis-diagnoses *beware the young multiple comorbidity patient with symptoms>findings* common hip pathologies

• labral tear • GT pain syndrome • snapping labral tear what? groin pain flexion rotation lock/catch why? labral tear – not enough bone (dysplasia)

• bone not providing enough coverage (support) for femoral head • labrum hypertrophies to provide that support labral tear – too much bone (FAI)

• at risk anatomy + at risk activity • wild card • reparative capacity

• young • active • at risk activities FAI – acetabular side (pincer impingement)

• overcoverage FAI – acetabular side too much bone everywhere FAI - acetabular side too much bone in one area focal overcoverage FAI – femoral side – CAM impingement not enough clearance AIIS impingement (subspine impingement)

• not enough clearance • possible history of AIIS avulsion **flexion crease pain with straight flexion • can be tough to differentiate from anterior overcoverage/ant CAM/ant labral tear

Image from Shibahara, healio 40(4):e725-e728 fascial disruption/core muscle/FAI

• the hip bone’s connected to the back bone… • restricted motion in hip • demands more motion from low back, pubic symphysis • puts abdominal fascia/muscles in vulnerable position

Image from Larson cm. sports health 2014. 6(2):139-144 Prevalence

• CT study of 100 joints (50 people) asymp • 39% of hips had at least 1 predisposing factor • M 48% > F 31% • 74% of hips aspherical GT pain syndrome

• abductor tendon tendinopathy/tear • bursitis • idiopathic • **pain with resisted abduction is their usual pain** • pain with high flexion and IR is usually only at GT snapping - internal

• iliopsoas over anterior acetabular rim • “I can hear it” • anatomy + movement • anatomy • overcoverage (pushes the labrum into the way) • can also happen with THA • movement • repetitive high flexion with rotation • ?compensation for lack of mobility elsewhere? • iliopsoas release??? • maybe in THA • better to treat underlying cause in native joint snapping external

• “my hip dislocates” • ITB moving over GT • “I can see it” • ITB fenestration??? • last resort

Image from aaos orthoinfo external snapping hip workup – history

FAI Arthrosis Abductor Tear RED FLAGS episodic episodic but ache at episodic +/- ache “all the time” night groin/Csign buttock GT rad below knee

worse with “loosens up” worse with worse with any flexion worse at night standing/walking movement rotation better with better with better with rest nothing improves it NSAIDs rest NSAIDs

Image from Dooley Can Fam physician 2008.54(1)42-47 workup – exam

FAI Arthrosis Abductor Tear RED FLAGS gait normal normal to antalgic limp walking aids with only limp when little demonstrable flared pathology n to low abd. normal +/- pain decreased abd unable to strength inhibition strength selectively activate glutei worse with straight flexion may pain at GT with unable to flex > 90 flexion be painless resisted abd rotation GT tenderness is GT tenderness not GT tenderness may tenderness not the usual pain common be the usual pain everywhere

Image from Dooley Can Fam physician 2008.54(1)42-47 workup - tests routine • screen for bony pathology • xray (AP pelvis, 45 degree Dunn view, false profile) FAI • CT with 3D reformats • screen for occult arthrosis • preop planning • MRI only if diagnosis uncertain AND your radiologists are experienced • joint injection if multiple pain generators • caution false negatives abductor tear • MRI fascial disruption/core muscle injury • MRI treatment – non operative/preoperative

• mechanism dependent • abductor and core strengthening • NSAIDs • activity modification • normalize gait/strength • teach muscle control (vital for postop)

• not everyone with pathology is a surgical candidate • arthrosis may be too advanced • ability to successfully rehab is critical treatment - operative

• address the underlying cause • undercoverage – PAO • overcoverage – acetabuloplasty • AIIS – recession • CAM – resection • tendon tear – repair • fascial disruption – repair rehabilitation

• phase 1 • manage inflammation • regain motor control iliopsoas tendonitis raw bone surfaces • phase 2 • gait • strength

emphasis on coordination, proprioception, balance • phase 3 • non-sagittal plane • endurance

ROM? internal ok many are delayed arthroscopy for FAI - outcomes

• mHHS 62 – 82 • 8 yr survival – 82.6% - M>F, young>old, BMI low>high • Revision – 5% at 2 yrs • BMI, age, sex arthroscopy for FAI - complications 8%

• DVT/PE – 0.1% • Infection – deep 0.04%, superficial 1% • femoral neck stress fracture – 0.1% • heterotopic ossification 0.8% • traction related • perineal numbness 1.4% • ankle/foot pain 0.8% • lateral thigh numbness -common postop, 1.6% beyond 6mo • iatrogenic chondral/labral injury 2% complications - avoidable

• wrong diagnosis • radiculopathy • missed secondary diagnosis • fascial disruption complications - avoidable

• residual deformity/pathology complications - avoidable

• rehab • too fast • too slow • just plain wrong • unknown • capsular stiffness and inflammation • poor response to NSAIDs, injections • adhesions less common hip pathologies

• ischiofemoral impingement • sciatic entrapment • hamstring avulsions sample case 1 – CAM FAI sample case 2 - overcoverage sample case 3 – mixed FAI

• dancer

• postop where is all this going?

• we have been here before • shoulder • pick up new diagnoses • treat them in less invasive ways • not everything is understood…so not everything has a name/treatment yet • subacromial impingement vs GT pain syndrome • history and physical are paramount • imaging can lead you astray • “what can I do?” vs “what should I do?” • rehab focuses on muscular control • despite being more constrained