Evaluaon of Hip Pain: Athletes & Pre-arthric Hips

John P Salvo, MD Sports Medicine Rothman Instute Clinical Associate Professor, Orthopaedic Surgery Thomas Jefferson University Hospital Philadelphia, PA Hip Injuries Hip injuries on the rise around MLB A-Rod, Utley among stars to deal with surgery, recovery Todd Zolecki MLB.com 6/4/09

PHILADELPHIA -- Mike Lowell followed the Marlins' strength and condioning programs religiously.He worked out properly.He stretched properly.But late in the season he felt ghtness in his right groin. Nobody could figure out why exactly because he had completed every program asked of him. But regardless of how hard he worked, the groin always ghtened.Lowell, who played for the Marlins from 1999-2005 before he joined the Red Sox in 2006, learned later he had a torn labrum in his hip and required surgery.He is not alone. Hip injuries have been diagnosed more frequently in Major League Baseball. Lowell, who had successful surgery to repair the labrum Oct. 20, 2008, is one of several notable players who have had hip surgeries in recent months. Others include Yankees third baseman Alex Rodriguez, Phillies second baseman Chase Utley, Mets first baseman Carlos Delgado and Royals third baseman Alex Gordon. Phillies pitcher Bre Myers had successful hip surgery Thursday."You know, Tommy John got a surgery named aer him. I think they should name this one aer me," Lowell joked.But why all the hip injuries all of a sudden?"I think the main reason is improved recognion of the pathology," said orthopedic surgeon and hip specialist Bryan T. Kelly, who peformed Myers' surgery at the Hospital for Special Surgery in New York. "They were treated with rest and an- inflammatories, and they would get persistent problems with it. Now we're beginning to recognize that a lot of problems that seem to be muscle strains or muscle pulls are ending up these [hip] problems.""Are these injuries occurring more frequently or are we just more aware of them and more precise at diagnosing them and treang them?" said Phillies team physician Michael Cicco, who is inmately familiar with hip injuries because of Utley and Myers. "It could be a combinaon of both of those. To answer that queson, you really need to have an understanding of the injury." Hip Injuries Hip Injuries Evaluaon of Hip Pain

• Anatomy • History • Physical Exam • Radiologic studies • Hip arthroscopy- INDICATIONS – Technique Evaluaon of Hip Pain • Anatomy – Bony anatomy • Femoral head and acetabulum – So ssue • Capsule and ligaments • Labrum • Ligamentum teres Evaluaon of Hip Pain • Anatomy – Hip is a true ball & socket joint – Highly constrained joint – Neurovascular structures • Femoral triangle • Lateral femoral cutaneous nerve • Sciac nerve Evaluaon of Hip Pain • Capsule and ligaments – Strongest ligaments in the body and are adapted to transfer forces from lower extremies to spine • Ligamentum teres • Labrum – Deepens the acetabulum and increases arcular congruence Labrum • Labrum is fibrocarlage • Has blood supply from the periphery • Previously tears thought to exist only with major trauma (posterior dislocaon) Labrum • “Sucon-seal” – Labrum has a sucon-seal effect on joint – When hip is reduced, labrum seals the synovial fluid around arcular carlage aiding in stabilizaon • Labrum acts as stabilizer and deepends acetabular cup Evaluaon of Hip Pain

• Normal hip has approximately 140 degree arc in flexion-extension – Only approximately 40 degree arc is used during jogging, with more during vigorous running Epidemiology • Hip & groin injuries occur less frequently than those of knee and ankle • Account for 5-9 % of injuries in high school athlecs • Rehabilitaon & recovery can be significant, so early recognion and treatment are essenal Common Causes of Hip Pain

• Arthris • Labral tears/ chondral lesions – Femoroacetabular impingement • Muscle strains • Avulsion/ apophyseal injuries • Snapping hip • Hip dislocaon/ subluxaon • Fracture Acute Injuries Causes of Pain Around the Hip Joint Intra-Articular Extra-Articular Hip Mimickers Labral tears* Iliopsoas tendonis* Athlec pubalgia Loose bodies* Iliobial band* Sports hernia Femoroacetabular impingement* Gluteus medius or minimus* Osteis pubis Capsular laxity* Greater trochanteric bursis* Ligamentum teres rupture* Stress fracture Chondral damage* Adductor strain Piriformis syndrome* Sacroiliac joint pathology *Condion can be treated arthroscopically From: Tibor & Sekiya Arthroscopy, 2008 24 (12): 1407-1421 Labral Tears • Eology – Femoroacetabular impingement – Acetabular dysplasia – Subluxaon Labral Tears • Femoroacetabular impingement – Impingement between anterior-lateral femoral neck and lateral acetabulum – CAM and “pincer” impingement • Pincer almost always associated with tears • Now thought to be a direct cause of labral tears – May be a precursor to arthris Labral Tears • Femoroacetabular impingement

Labral Tears • Usually history of minor traumac injury – Twisng or slipping type of injury – Can be contact injury (soccer, ice hockey) – Many do not recall any significant injury • Pain is usually sharp or intense and deep in hip joint • Can have catching, popping, and frank locking of hip Labral Tears • Groin pain • Click in hip (can be audible) • Limitaon of moon – especially sing, internal rotaon and flexion Sports Hernia • Tear at distal rectus abdominus and proximal adductor longus • Causes pain at area of symphysis pubis and superior ramus • Pain with rotaon and resisted sit-up • Treatment: Conservave (rehab, injecons) – Surgery • Pelvic floor reconstrucon Physical Examinaon Physical Examinaon Labral Tears • Physical examinaon – Gait and posture – Palpaon for any tender areas • Greater trochanter (bursis) • Superior ramus/ symphysis (sports hernia) • Inferior ramus (adductor strain/ tear) – If pathology is truly intra-arcular, you cannot reproduce symptoms by palpaon Labral Tears • Physical examinaon – Muscle strength – Neurovascular exam – Evaluate for true hernia – Evaluate for sports hernia/ athlec pubalgia • Small tear between distal rectus abdominus and adductor inseron on symphysis • Pain to palpaon in this region that reproduces the symptoms Labral Tears • Physical examinaon – Reproducon of hip pain or pop/click with specific maneuvers – Anterior labrum • Flexion, abducon, external rotaon followed by extension, adducon, internal rotaon (FADDIR) • Usually pain in FABER posion – Posterior labrum • Passive flexion, posterior load Labral Tears • Physical examinaon – Impingement sign • Hip in neutral posion • Flexion over 90 degrees, internal rotaon reproduces pain – Oen described as “pinching” sensaon • Can overlap with symptoms of labral tear Labral Tears • Physical examinaon – Femoroacetabular Impingement • Usually decreased ROM • Internal rotaon in 90 degrees of flexion limited and painful • Hip tends to slide into abducon with flexion Labral Tears • Physical examinaon – “C sign” • Paents will cup their hand around their hip when asked where to locate their pain – Piriformis test • Hip flexed to 60 degrees and downward pressure on knee (pain = ght piriformis; radicular = sciac) – Ober test (IT band) – Thomas test (Flexion contracture) Labral Tears • Radiologic studies – X-rays – MRI – Direct MR Arthrogram • Best study, but sll limited • Have radiologist inject the joint with lidocaine and corcosteroid (diagnosc and therapeuc) MRI MRI Labral Tears • Treatment – Conservave • Rehabilitaon and recondioning • NSAIDs • Modify acvies • Corcosteroid injecon – Surgical • Open • Arthroscopy Hip Arthroscopy • Indicaons – Labral tears – Loose bodies – Chondral lesions • Lateral impact – Femoroacetabular impingement (FAI) – Snapping hip – Sepc hip Hip Arthroscopy • Hip Arthroscopy – Technically demanding procedure – Excellent procedure for intra-arcular problems in young paents – Labral debridement, labral repair – Removal loose bodies – Chondroplasty – Decompression for impingement Hip Arthroscopy • Complicaons – Chondral injury (iatrogenic) – Neurologic injury • Pudendal nerve, lat fem cutaneous nerve – Sffness – Fracture – Blood clot Hip Arthroscopy • Supine or lateral • C-arm • Need tracon to distract the hip joint – 20 to 50 lbs with pelvis stabilized • Specialized instrumentaon to safely work in the highly constrained hip joint – Curved shavers and flexible ablaon probes – Long cannulas to safely enter hip joint Hip Arthroscopy Hip Arthroscopy Hip Arthroscopy Hip Arthroscopy Hip Arthroscopy Hip Arthroscopy Hip Arthroscopy Hip Arthroscopy Hip Arthroscopy Hip Arthroscopy Summary • Hip pain is common • Perform a thorough & focused history and physical exam to determine eology • Younger- think carlage (labrum), FAI, or dysplasia • Older- think DJD, FAI, carlage Summary • Imaging is crical – X-rays weight-bearing • <2mm medial or superior joint space DJD – Direct MR Arthrogram • Treatment depends on age, pathology, and status of the joint surface – Young, pre-arthric, carlage, FAI • Arthroscopy or open joint preservaon – Older, DJD, loss of joint space • THA