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4 Dr Gustavo Reque Ryderg Hip and Thigh DIU 2017.Key DIPLOME UNIVERSITAIRE -DU PAIN 2017 INTERVENTIONAL ANALGESIA : CONCEPTS AND TECHNIQUES FACULTÉ DE MÉDECINE MONTPELLIER - DUBAI HEALTH AUTHORITY 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 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 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 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: Fever, Inability to bear weight, ESR >44 mm/hour, WBC > 12x 109/l. Caird MS, Flynn JM, Leung YL, et al. Factors distinguishing septic arthritis 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 physical examination 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 pelvis 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 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 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 groin 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 bursitis 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
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