DIPLOME UNIVERSITAIRE -DU PAIN 2017 INTERVENTIONAL ANALGESIA : CONCEPTS AND TECHNIQUES

FACULTÉ DE MÉDECINE MONTPELLIER - DUBAI HEALTH AUTHORITY MSK ASSESSMENT AND PATHOLOGY: AND

DR. GUSTAVO REQUE RYDBERG

MBBS, MSc SPORTS MED, MSc PAIN MED, DIP MSK US, DIU Osteopathie - Med Manuelle MSK ASSESSMENT AND PATHOLOGY: HIP AND THIGH

DR. GUSTAVO REQUE RYDBERG

MBBS, MSc SPORTS MED, MSc PAIN MED, DIP MSK US, DIU Osteopathie - Med Manuelle DISCLOSURE

I have no financial conflict to disclose HIP AND THIGH

OUTLINE

MSK ASSESSMENT US EXAMINATION TECHNIQUE PATHOLOGY EQUIPMENT

❖ Depends on body habitus/ BMI. ❖ Linear array 10MHz with virtual convex. ❖ Curvi-linear transducer 5-7MHz. EQUIPMENT

❖ Depends on body habitus/ BMI. ❖ Linear array 10MHz with virtual convex. ❖ Curvi-linear transducer 5-7MHz. EPIDEMIOLOGY

120 NIVEL study confirms incidence of non-traumatic hip 100 pathology at 148.1/100 000. Study population 73,954 children aged 0-14 (Holland). 80

The highest incidence was 60 found in Transient at 76.2/100 000 (51.48% of all 40 cases). Mean age: 4.7yrs female, 5.1yrs male. 20

Krul, M et al. Acute non-traumatic hip pathology in children: incidence and presentation in family practice. Family Practice: 2010, 27 (2), 166-170.

0 All hip pathology Transient Synovitis EPIDEMIOLOGY HIP PAIN

120 NIVEL study confirms incidence of non-traumatic hip 100 pathology at 148.1/100 000. Study population 73,954 children aged 0-14 (Holland). 80

The highest incidence was 60 found in Transient Synovitis at 76.2/100 000 (51.48% of all 40 cases). Mean age: 4.7yrs female, 5.1yrs male. 20

Krul, M et al. Acute non-traumatic hip pathology in children: incidence and presentation in family practice. Family Practice: 2010, 27 (2), 166-170.

0 All hip pathology Transient Synovitis EPIDEMIOLOGY

Differential Dx:

Legg-Calve-Perthes LCPD: 8.8per 100 000 persons – year. (varies eg: Japan 0.9/100 000 to Liverpool 21.1/ 100 000).

Median age: 10yrs (NIVEL) 5 x more common in boys EPIDEMIOLOGY

Differential Dx

Slipped Capital Femoral Epiphysis (SCFE): 5.9 per 100 000 person-year. Also varies, USA 10.8 / 100 000 (Lehman et al.).

Median age: 9.5yrs (NIVEL)

Lehmann CL, Arons RR, Loder RT, Vitale MG. The epidemiology of slipped capital femoral epiphysis: an update. J Pediatr Orthop (2006) 26:286–90. EPIDEMIOLOGY

Differential Dx:

Septic Arthritis: incidence unknown. One study reported 34 suspected cases in USA from 2000 – 2004.

As per Kocher at al: , Inability to bear weight, ESR >44 mm/hour, WBC >

12x 109/l.

Caird MS, Flynn JM, Leung YL, et al. Factors distinguishing from transient synovitis of the hip in children. A prospective study. J Bone Joint Surg Am. Jun 2006;88(6):1251-7 EPIDEMIOLOGY

Nogier et al. provided a study reviewing 292 cases with mechanical hip pain between the ages of 16 – 50 yrs.

Mean age in study: 35yrs, 62% males.

A. Nogier, N. Bonin, O. May, J.-E. Gedouin, L. Bellaiche, T. Boyer, M. Lequesne, the French Arthroscopy Society. Descriptive epidemiology of mechanical hip pathology in adults under 50 years of age. Prospective series of 292 cases: Clinical and radiological aspects and physiopathological reviewOriginal Research Article. Orthopaedics & Traumatology: Surgery & Research, Volume 96, Issue 8, Supplement, December 2010, Pages S53-58. EPIDEMIOLOGY

Prevalence of morphological abnormalities

5% 12% 31% Dysplasia 15% Dysplasia+CAM Effect CAM Effect CAM+Pincer effect 33% 4% Pincer Effect Normal aspect EPIDEMIOLOGY

FAI (Clohisy) Pincer 8%

CAM 48%

CAM+ Pincer 44% HIP JOINT MSK ASSESSMENT HIP

Diagnosis of hip pathology is challenging. An avg. 3.3 providers before being correctly diagnosed.

False positive with MRI and MRA are common.

Accurate and efficient is valuable.

Reiman et al. provided systematic review and meta-analysis of hip physical examination (HPE). Reiman MP, Goode AP, Hegedus EJ, et al. Diagnostic accuracy of clinical test of the hip : a systematic review with meta-analysis. Br J Sports Med. Published online first: 7 July 2012 MSK ASSESSMENT HIP

TRENDELENBURG’S SIGN:

Positive sign was considered when contralateral revealed angle on pelvic-femoral angle >83* with specified duration of 30secs.

Sensitivity SN: 55%

Specificity SP: 70%

Positive likelihood ratio +LR: 1.83 MSK ASSESSMENT HIP

RESISTED EXTERNAL DEROTATION TEST: Gluteal

Positive when patient refers spontaneous reproduction of pain when returning leg to neutral from external rotation.

SN: 88% SP: 97.3% +LR: 32.6

Demonstrated ability to modify post-test probability of gluteal tendinopathy. MSK ASSESSMENT HIP

RESISTED EXTERNAL DEROTATION TEST: Gluteal tendinopathy

Positive when patient refers spontaneous reproduction of pain when returning leg to neutral from external rotation.

SN: 88% SP: 97.3% +LR: 32.6

Demonstrated ability to modify post-test probability of gluteal tendinopathy. MSK ASSESSMENT HIP

FADDIR Test

(Flexion-adduction- internal rotation)

Impingement, labral tear, articular pathology.

MRA criterion: SN 94% SP 8%

Sx Arth crit. SN 99% SP 7%

Video Mr Peter Winters MSK/Sports Physiotherapist MSK ASSESSMENT HIP

FADDIR Test

(Flexion-adduction- internal rotation)

Impingement, labral tear, articular pathology.

MRA criterion: SN 94% SP 8%

Sx Arth crit. SN 99% SP 7%

Video Mr Peter Winters MSK/Sports Physiotherapist MSK ASSESSMENT HIP

THOMAS TEST

With both legs up to patient’s chest, tested leg is passively lowered into extension or active hip flexion while reclining supine.

Hip extension recreates greatest forces on the hip joint.

SN 89% SP 92% +LR 11.1

Video Mr Peter Winters MSK/Sports Physiotherapist MSK ASSESSMENT HIP

THOMAS TEST

With both legs up to patient’s chest, tested leg is passively lowered into extension or active hip flexion while reclining supine.

Hip extension recreates greatest forces on the hip joint.

SN 89% SP 92% +LR 11.1

Video Mr Peter Winters MSK/Sports Physiotherapist MSK ASSESSMENT HIP

Other tests (Sports related pain):

Single Adductor Test SN 30% SP 91%

Bilateral Adductor Test SN 54% SP 93%

Squeeze Test SN 43% SP 91% PATHOPHYSIOLOGY

Pathophysiology of OA (cartilage):

Structural framework of cartilage comprises:

Collagens

Proteoglycans

Glycoproteins

Tissue fluid (cations)

Glycosaminoglycans (anions) GAG’s. PATHOPHYSIOLOGY

Cartilage histology: architecture and matrix composition will provide Dx objectives.

Superficial zone: 1st affected by OA. Low GAG, high Collagen content, parallel to surface.

Middle Zone: higher GAG. Col oblique.

Deep zone: High GAG. Col perpendicular.

Tidemark transition into subchondral bone. PATHOPHYSIOLOGY

OA Research Society International (OARSI) grading:

Grade I and II: Cartilage oedema and early GAG depletion. Some superficial fissuring.

Grade III: Vertical fissures into middle zone. No significant cartilage loss. Still reversible. IMAGING.

Grade IV: increased fissuring, cartilage erosion

Grade V and VI: almost complete erosion of articular cartilage. Sclerosis.

Pritzker KP, Gay S, Jimenez SA, et al. , Osteoarthritis cartilage histopathology: grading and staging. Osteoarthritis Cartilage 2006;14;13-29. IMAGING

XRAY:

Most common Dx method for OA.

Narrowing joint space (most sensitive), osteophyte formation, subchondral sclerosis and cysts.

Kellgren and Lawrence grading.

Kellgren JH, Lawrence JS. Radiological assessment of osteo-arthrosis. Ann Rheum Dis 1957: 16:494-502. IMAGING

While MR arthrography has been advocated for the evaluation of labral pathology, this technique requires intraarticular administration of gadolinium-based contrast, a procedure that is not without risks. IMAGING

XRAY views for Hip:

Systematic review of Xray assessment of the YOUNG HIP considered (ANCHOR):

AP view

Cross table lateral view

Dunn view 45* or 90*

Frog leg view

False profile view

Clohisy JC et al., A Systematic Approach to the Plain Radiographic Evaluation of the Young Adult Hip. J Bone Joint Surg Am. 2008;90 Suppl 4:47-66. IMAGING

Longitudinal assessment using quantitative MRI will allow for the establishment of quantitative threshold values of the dGEMRIC (Delayed Gadolinium Enhanced MRI of the Cartilage) index, T2 relaxation time, or T1ρ (Spin lattice relaxation in the rotating frame) that are predictive of osteoarthritis and joint degradation that require arthroplasty. IMAGING

ULTRASOUND

Particularly useful in Dx hip effusion: clinical relevance in Toxic Synovitis or Septic Arthritis.

Doppler can reveal synovial vascularity. Synovitis could be a predictive factor for OA. ANTERIOR HIP

IA HIP EFFUSION: ANECHOIC DISTENSION OF ANTERIOR RECESS ANTERIOR HIP

Hip effusion with synovitis.

Doppler enhancement positive. ANTERIOR HIP PSOAS ANTERIOR HIP

❖ Ultrasound Images: Psoas (snapping) LAX

Hypoechoic swelling: Psoas LAX Normoechoic Psoas LAX ANTERIOR HIP

❖ Ultrasound Images: Psoas (snapping) SAX

Psoas SAX: Normal Psoas SAX: Hypoechoic swelling ANTERIOR HIP

Ultrasound Images: Psoas

Psoas hematoma LAX: Anechoic distension Psoas hematoma SAX ANTERIOR HIP

Psoas Calcific Tendinopathy SAX LATERAL HIP

❖ Greater trochanter: Greater Trochanteric Pain Syndrome GTPS. ❖ Tendinopathy or around the trochanteric region are the main indication for US examination of the lateral hip (S. Bianchi, C. Martinoli et al. Ultrasound of the Musculoskeletal System).

❖ Affects between 10-25% of population.

❖ Lifetime incidence 20%. (Segal NA et al. Arch Phys Med Rehabil 2007;88)

❖ Highest incidence in 40-60yr old, 3-4:1 ratio > female.

❖ Mean age 62.4 yrs (Segal et al.) LATERAL HIP

❖ Key Landmark: Apex of the greater trochanter between the anterior and the lateral facets. ❖ Bony landmarks are essential. Image and Table from Jacobson JA. Fundamentals of Musculoskeletal ❖ SAX view to Ultrasound 2nd Ed, 2013. the . LATERAL HIP

❖ Key Landmark: Apex of the greater trochanter between the anterior and the lateral facets. ❖ Bony landmarks are essential. Image and Table from Jacobson JA. Fundamentals of Musculoskeletal ❖ SAX view to Ultrasound 2nd Ed, 2013. the femur. LATERAL HIP

GTPS etiology: Recent studies favor pathological abductor tendon as opposed to trochanteric bursitis. (Connell at el. 2003: Cvitanic et al. 2004: Segal NA et al. 2007: Mallow M et al. 2014)

Gluteus medius (anterior and posterior portion of tendon) > gluteus minimus.

Also referred as “Rotator cuff tear of the hip”

Image from ESSR LATERAL HIP

❖ Anterior facet: Insertion of gluteus minimus.

❖ Posterior to the anterior facet is the lateral facet.

❖ Insertion of the Gluteus Medius.

❖ Iliotibial band lies superficial to gluteus medius. Hyperechoic band of tissue. LATERAL HIP

Pathological findings:

Anechoic distension over posterior facet suggesting subgluteus maximus bursitis. Interstitial hypoechoic cleft in gluteus medius. LATERAL HIP

Pathological findings:

Anechoic distension over posterior facet suggesting subgluteus maximus bursitis. Interstitial hypoechoic cleft in gluteus medius. LATERAL HIP

❖ Gmed calcific tendinopathy over superolateral and lateral facet with anechoic linear cleft suggesting longitudinal tears. LATERAL HIP

❖ Gmed calcific tendinopathy over superolateral and lateral facet with anechoic linear cleft suggesting longitudinal tears. LATERAL HIP

Pathological finding:

Suspected hypoechoic swelling in hyperchoic fibrillar tissue superficial to gluteus medius (trochanteric apex). Doppler imaging does not reveal neovascularities. LATERAL HIP

❖ US guided procedures of GTPS: ❖ Tendon fenestration ❖ PRP ❖ Steroids LATERAL HIP

❖ Common site for hip contusions: bicycle fall LATERAL HIP LATERAL HIP LATERAL HIP

❖ MOREL LAVALLE: SEROMA ❖ Closed degloving following acute trauma (falling off bicycle). Hemolymphatic mass. POSTERIOR HP

PIRIFORMIS SYNDROME

Incidence between 1% - 6% of LBP . Fishman, LM at al . Piriformis syndrome : diagnosis, treatment and outcome—a 10 year study. Arch of PM and R, March 2002.

3:1 in women.

Pathophysiology:

Overuse, trauma, hypertrophy, secondary to dLBP, pelvic dysfunction, gluteal weakness, etc.. Smoll NR et al : Variations of the piriformis and sciatic nerve with clinical consequence: a revie. Clinical Anatomy (Jan 2010)

Sciatic entrapment syndrome. POSTERIOR HIP

Diagnosis:

Exclusion Dx: discopathy?

MSK Assessment

Electromyography

Imaging: poor correlation.

MR/Neurography: specific Neural structure MRI. 93% specificity and 64% sensitivity in distinguishing Piriformis syndrome (muscle asymmetry and nerve hyperintensity). Filler AG et al, of nondisc origin and piriformis syndrome: diagnosis by magnetic resonance neurography and interventional magnetic resonance imaging with outcome study of resulting treatment. J Neurosurg Spine, Feb 2005. POSTERIOR HIP

MSK Assessment:

Deep gluteal pain referred distal. tenderness in sciatic notch.

Agg’s with walking, sitting.

Tests: FAIR test, Freiberg test, FABER, Pace test, seated piriformis stretch test, . None conclusive.

FAIR test POSTERIOR HIP

MSK Assessment:

Deep gluteal pain referred distal. tenderness in sciatic notch.

Agg’s with walking, sitting.

Tests: FAIR test, Freiberg test, FABER, Pace test, seated piriformis stretch test, Palpation. None conclusive.

FAIR test POSTERIOR HIP

Rediagnosis of cases of suspected Piriformis Sme. (as per Filler et al. MR Neurography):

Piriformis Syndrome (67.8%) Distal nerve root entrapment (6%) Ischial Tunnel Syndrome (4.7%) Discogenic Pain (3.4&) Pudendal nerve entrapment with referred pain (3%) Distal Sciatic entrapment (2.1%) Lumbosacral plexus entrapment (1.3%) Lateral disc herniation (1.3%) Nerve root injury due to spinal injury (1.3%) Inadequate nerve root decompression (0.8%) Lumbar stenosis ((0.8%) SIJ inflammation (0.8%) Lumbosacral plexus tumor (0.4%) Sacral fracture (0.4%) POSTERIOR HIP

Rediagnosis of cases of suspected Piriformis Sme. (as per Filler et al. MR Neurography):

Piriformis Syndrome (67.8%) Distal nerve root entrapment (6%) Ischial Tunnel Syndrome (4.7%) Discogenic Pain (3.4&) Pudendal nerve entrapment with referred pain (3%) Distal Sciatic entrapment (2.1%) Lumbosacral plexus entrapment (1.3%) Lateral disc herniation (1.3%) Nerve root injury due to spinal injury (1.3%) Inadequate nerve root decompression (0.8%) Lumbar stenosis ((0.8%) SIJ inflammation (0.8%) Lumbosacral plexus tumor (0.4%) Sacral fracture (0.4%) POSTERIOR HIP

Deep Gluteal Syndrome.

Failed treatment due other possibe sources of pain such as:

Obturator Internus (fibrous bands) Ischiofemoral pathology Quadratus femoris POSTERIOR HIP

Treatment:

Conservative: NSAID, Physiotherapy

US guided injections:

Local Anesthetics Steroids (79% patients > 50% improvement) Cassidy et al. Surg Radiol Ant. 2012

PRP vs AB Hydrodissection Hyaluronates Botox Saline vs HVI

Botox

Surgery: Endoscopy INGUINAL

❖ Abdominal wall anomalies? ❖ Start mid-, below umbilicus. ❖ Lateral margin of Rectus Abdominis, distal sweep until inferior epigastric artery can be identified: Spingelian hernias (between RFem and Lateral Abdominal wall). INGUINAL

❖ Abdominal wall anomalies? ❖ Start mid-abdomen, below umbilicus. ❖ Lateral margin of Rectus Abdominis, distal sweep until inferior epigastric artery can be identified: Spingelian hernias (between RFem and Lateral Abdominal wall). INGUINAL

SYMPHYSIS PUBIS INGUINAL

SYMPHYSIS PUBIS INGUINAL INGUINAL INGUINAL

Inferior Epigastric Artery INGUINAL

Inferior Epigastric Artery INGUINAL

❖ Landmark: where inferior epigastric artery (IEA) joins external iliac artery. ❖ Superior and lateral to this is the deep inguinal ring. ❖ Direct Hernias: Originate Medial to IEA ❖ Indirect hernias: Originate Lateral to IEA ❖ Valsalva INGUINAL

❖ Landmark: where inferior epigastric artery (IEA) joins external iliac artery. ❖ Superior and lateral to this is the deep inguinal ring. ❖ Direct Hernias: Originate Medial to IEA ❖ Indirect hernias: Originate Lateral to IEA ❖ Valsalva INGUINAL

Valsalva INGUINAL

Valsalva ANTERIOR THIGH

❖ Primary structure of interest is the Quadriceps muscle (4 muscles). ❖ Rectus Femoris ❖ Vastus Intermedius ❖ Vastus Medialis ❖ Vastus Lateralis ANTERIOR HIP

Quad - Rectus Fem Strength Thomas Test ANTERIOR HIP

Quad - Rectus Fem Strength Thomas Test ANTERIOR HIP

❖ Rectus Femoris tendon is the landmark tendon. ❖ Proximal tendon is of special interest. ❖ Direct head: AIIS ❖ Indirect head: Lateral to AIIS. Challenging to view. ANTERIOR THIGH

❖ Proximal 1/3 of anterior thigh we find landmark Fem tendon ANTERIOR THIGH

❖ Proximal 1/3 of anterior thigh we find landmark Fem tendon ANTERIOR THIGH ANTERIOR THIGH ANTERIOR THIGH

SAX LAX ANTERIOR THIGH

EXTENDED FIELD OF VIEW MEDIAL THIGH

❖ Medial Thigh Structure of interest: ❖ Femoral Artery: medial to Rectus Femoris and V medialis. Superficial to it is Sartorious. ❖ Medial and posterior to these are the Adductors. MEDIAL THIGH MEDIAL THIGH MEDIAL THIGH

❖ Adductors: ❖ Most superficial is Adductor Longus (most commonly strained). ❖ Add Brevis ❖ Add Longus ❖ Obturator Nerve: Between Adductor layers. ❖ Gracilis is superficial and medial to Adductors. MEDIAL THIGH

LAX MEDIAL THIGH

Add Longus

Add Brevis

Add Mag

LAX MEDIAL THIGH

SAX MEDIAL THIGH

AL

AB

AM

SAX MEDIAL THIGH

Assess insertion of adductors MEDIAL THIGH

Assess insertion of adductors POSTERIOR THIGH

❖ Structures of interest of the posterior thigh: ❖ Semimembranosus. ❖ Semitendinosus. ❖ Biceps Femoris. ❖ Sciatic nerve. POSTERIOR THIGH

❖ US Assessment: ❖ Start with SAX in mid- proximal thigh. ❖ SAX view of SemiT/B Fem conjoined tendon as well as SemiM. ❖ Triangular landmark with sciatic nerve. POSTERIOR THIGH

❖ US Assessment: ❖ Start with SAX in mid- proximal thigh. ❖ SAX view of SemiT/B Fem conjoined tendon as well as SemiM. ❖ Triangular landmark with sciatic nerve. POSTERIOR THIGH

SEMI T B FEM

SN POSTERIOR THIGH

SEMI T B FEM

SN POSTERIOR THIGH POSTERIOR THIGH POSTERIOR THIGH POSTERIOR THIGH POSTERIOR THIGH

LH B FEM POSTERIOR THIGH

LH B FEM POSTERIOR THIGH

SemiT

SemiM POSTERIOR THIGH

SemiT

SemiM POSTERIOR THIGH

CONJOINED TENDON INSERTION POSTERIOR THIGH

CONJOINED TENDON INSERTION HIP AND THIGH

❖ HIP

❖ MSK Assessment valuable.

❖ Imaging: MRI vs XRAY vs US.

❖ “Trochanteric bursitis” vs Gluteus Medius

❖ Rec Fem insertion.

❖ THIGH

❖ Quadriceps and Hamstrings: Insertional vs miss-substance tears.

❖ Adductors: Add Longus. HIP AND THIGH

TAKE HOME POINTS

❖ HIP

❖ MSK Assessment valuable.

❖ Imaging: MRI vs XRAY vs US.

❖ “Trochanteric bursitis” vs Gluteus Medius

❖ Rec Fem insertion.

❖ THIGH

❖ Quadriceps and Hamstrings: Insertional vs miss-substance tears.

❖ Adductors: Add Longus.

شكرا - GRACIAS – THANK YOU – MERCI