The Hip and the Neuromuscular Physician From EDX to Coxa Saltans Keith A. J. Sequeira MD Thomas A. Miller, MD Timothy J. Doherty, MD Timothy P. Carey, MD Douglas C. Ross, MD 2009 COURSE D AANEM 56th Annual Meeting San Diego, California Copyright © October 2009 American Association of Neuromuscular & Electrodiagnostic Medicine 2621 Superior Drive NW Rochester, MN 55901 Printed by Johnson Printing Company, Inc. ii The Hip and the Neuromuscular Physician From EDX to Coxa Saltans Faculty Timothy Carey, MD, FRCS(C) Thomas A. Miller, BSc, MD, FRCP(C) Associate Professor Associate Professor University of Western Ontario Schulich School of Medicine and Dentistry London, Ontario, Canada Department of Physical Medicine & Rehabilitation Dr. Carey is a graduate of the University of Ottawa school of medicine and University of Western Ontario also completed his orthopaedic residency there after a year internship at St. Joseph’s Health Care/Mount Hope the Toronto East General hospital. Two years of fellowship training in pae- London, Ontario, Canada diatric orthopaedic surgery followed at the Childrens Hospital of Eastern Dr. Miller is a graduate of Queen’s University and trained in physical medi- Ontario and the Shriners Hospital, Tampa Unit. Dr. Carey has been on cine and rehabilitation at the University of Ottawa. He then performed staff at the London Health Sciences Centre since 1995 and is currently an a fellowship in clinical neurophysiology at the University of New South associate professor at the University of Western Ontario (UWO), program Wales, Australia. He is the medical director of the musculoskeletal rehabili- director of the orthopaedic residency training program UWO, and chief tation program, director of the electrodiagnostic laboratory, the consultant of paediatric orthopaedics division. His clinical interests include spinal physiatrist with the Hand and Upper Limb Centre, and co-director of the deformity, cerebral palsy, and limb lengthening. Peripheral Nerve Clinic, St. Joseph’s Health Centre, London, Canada. Tom is an associate professor in the Schulich School of Medicine and Dentistry Timothy J. Doherty, MD, PhD, FRCP(C) at the University of Western Ontario. Dr Miller is currently the president of the Canadian Association of Physical Medicine and Rehabilitation. Associate Professor Departments of Clinical Neurological Sciences and Rehabilitation Medicine The Schulich School of Medicine and Dentistry University of Western Ontario London, Ontario, Canada Dr. Doherty is an associate professor in the Departments of Clinical Neurological Sciences and Physical Medicine and Rehabilitation at the University of Western Ontario in London, Ontario. In 2005, he was named Canada Research Chair in Neuromuscular Function in Health, Aging, and Disease. He is a consultant physiatrist and clinical neuro- physiologist at London Health Sciences Centre. Dr. Doherty is the author of over 60 peer-reviewed papers. His research focuses on the examina- tion of the motor system and motor units in health, aging, and disease. Additionally, his research is aimed at understanding the physiological basis of impairment in the motor system and rehabilitation interventions to limit disability. No one involved in the planning of this CME activity had any relevant financial relationships to disclose. Authors/faculty have nothing to disclose. Course Chair: David Bryan Shuster, MD The ideas and opinions expressed in this publication are solely those of the specific authors and do not necessarily represent those of the AANEM. iii Douglas C Ross, MD, MEd, FRCS(C) Keith Sequeira, MD, FRCP(C) Chair, Division of Plastic Surgery Associate Director Co-Director, Peripheral Nerve Clinic Regional Spinal Cord and Brain Injury Rehabilitation Schulich School of Medicine and Dentistry Parkwood Hospital University of Western Ontario London, Ontario, Canada London, Ontario, Canada Dr. Sequeira is a graduate of the University of Toronto and completed his Dr. Ross is a graduate of the University of British Columbia (BSc, MD). residency at the Albany Medical Center in New York where he was chief He also holds a Masters of Education from the Ontario Institute for resident during his final year. He completed a fellowship in electrodiagnos- Studies in Education at the University of Toronto. He completed his tic and sports medicine at Michigan State University. Dr. Sequeira is cur- plastic surgery training at the University of Toronto followed by two years rently the associate director of the Regional Spinal Cord and Brain Injury of fellowship training in hand and microsurgery at Toronto, and hand Rehabilitation Programs at Parkwood Hospital in London, Ontario. He surgery in Louisville, Kentucky. He has been a faculty member at the holds an appointment at the University of Western Ontario as an associate University of Western Ontario (UWO) since 1992. Dr. Ross is chair of professor and residency program director in the Department of Physical the Division of Plastic Surgery at UWO, a staff member at the Hand & Medicine & Rehabilitation. He is the director of the undergraduate muscu- Upper Limb Centre at St. Joseph's Health Centre, and co-director of the loskeletal curriculum at the Schulich School of Medicine at the University Peripheral Nerve Clinic in London. He serves as secretary of the Canadian of Western Ontario. He runs a spasticity clinic at Parkwood Hospital and Society for Surgery of the Hand and is a member of the American Society is actively involved in spinal cord and brain injury research, medical school for Surgery of the Hand, the American Society for Peripheral Nerve, and education and has been in active practice for over 10 years. the American Society for Reconstructive Microsurgery. His clinical inter- ests include upper extremity surgery, reconstructive microsurgery and pe- ripheral nerve surgery. He also has a strong interest in surgical education. iv Practice Management AANEM Course Please be aware that some of the medical devices or pharmaceuticals discussed in this handout may not be cleared by the FDA or cleared by the FDA for the specific use described by the authors and are “off-label” (i.e., a use not described on the product’s label). “Off-label” devices or pharmaceuticals may be used if, in the judgement of the treating physician, such use is medically indi- cated to treat a patient’s condition. Information regarding the FDA clearance status of a particular device or pharmaceutical may be obtained by reading the product’s package labeling, by contacting a sales representative or legal counsel of the manufacturer of the device or pharmaceutical, or by contacting the FDA at 1-800-638-2041. v The Hip and the Neuromuscular Physician From EDX to Coxa Saltans Contents Faculty ii Objectives v Course Committee vi Three Important Musculoskeletal Conditions Involving the Groin and Buttock: Femoroacetabular Impingement, “Sports Hernia”, and Trochanteric Bursal Pain Syndrome 1 Keith Sequeira, MD, FRCP(C); Douglas D.R. Naudie, MD, FRCS(C) The Diagnosis and Management of Piriformis Syndrome: Myths and Facts 9 Thomas A Miller, M.D. FRCP(C); Douglas C Ross, MD, MEd, FRCS(C) Lumbosacral Plexopathy: The Clinical and Electrodiagnostic Spectrum 19 Timothy J. Doherty, MD, PhD Neuromuscular Disease and the Hip: An Orthopedic Perspective 25 Timothy P. Carey, MD, FRCS(C) Evaluation and Surgical Treatment of Neurologic Injuries Around the Hip 33 Douglas C. Ross, MD, MEd, FRCS(C); Thomas A. Miller, MD, FRCP(C) O BJECTIVES — After attending this session, participants will be able to (1) distinguish and contrast presentations of musculoskeletal hip and pelvic pain for the clinical EDX physician, (2) summarize the myth and facts about piriformis syndrome, (3) develop a clinical and EDX approach to lumbosacral plexopathy, (4) demonstrate and recognize orthopedic treatment options for the hip, pelvis, and lower limb in neuromuscular disease, and (5) appreciate the surgical treatment options in nerve injury including “neurotization” for lower-limb nerve injuries. P REREQUISITE —This course is designed as an educational opportunity for physicians. A CCREDIT A TI O N ST A TEMENT —The AANEM is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education (CME) for physicians. CME CREDIT —The AANEM designates this activity for a maximum of 3.25 hours in AMA PRA Category 1 Credit(s).TM If purchased, the AANEM designates this activity for 2 AMA PRA Category 1 Credit(s).TM This educational event is approved as an Accredited Group Learning Activity under Section 1 of the Framework of Continuing Professional Development (CPD) options for the Maintenance of Certification Program of the Royal College of Physicians and Surgeons of Canada. Each physician should claim only those hours of credit he or she actually spent in the educational activity. CME for this course is available 10/09 - 10/12. vi AANEM Course 2008-2009 AANEM COURSE COMMITTEE Anthony E. Chiodo, MD, Chair Ann Arbor, Michigan Shawn J. Bird, MD Mazen M. Dimachkie, MD Benjamin S. Warfel, II, MD Philadelphia, Pennsylvania Kansas City, Kansas Lancaster, Pennsylvania Gary L. Branch, DO John E. Hartmann, MD Dewitt, Michigan Augusta, Georgia John E. Chapin, MD David Bryan Shuster, MD Walla Walla, Washington Dayton, Ohio 2008-2009 AANEM PRESIDENT Michael T. Andary, MD, MS East Lansing, Michigan AANEM Course Practice Management 1 Three Important Musculoskeletal Conditions Involving the Groin and Buttock: Femoroacetabular Impingement, “Sports Hernia”, and Trochanteric Bursal Pain Syndrome