Differential diagnosis of internal hip pain, physical examination, and imaging of the non-arthritic hip.

1. Causes of Internal Hip Pain
Differential Diagnosis and How to Diagnose
Itamar Botser

2. Cause - Effect
Underling
Problem Asymptomatic
Damage Pain

3. Intra-articular Pathologies
•Cam Structural
Underling Problem
•Pincer Damage
Pain Generators
•Dysplasia
•Perthes •Labral Tears
•SCFE •Chondral Damage
•High Femoral Anteversion •Synovitis
•Micro-Instability •Ligamentum Teres Tears
•Loose Bodies
•Iliopsoas Tendon Snapping
•PVNS Disease •Iliopsoas Bursitis
•Synovial Chondromatosis •Capsular Stress
•Arthritis
•Osteonecrosis
•Transient Osteoporosis
•Inflammatory Diseases

4. HISTORY OF PRESENT ILLNESS:
• 17-year-old gentleman who complains of left
hip pain for the last 6 months.
• He denies any incident or fall that caused the
injury.
• He describes multiple groin pulls that he had
in the past, as well as hip flexor injuries that
he thought was the cause of this.

5. Sport
• He plays basketball and football, and recently
received a full scholarship to Santa Clara
University for baseball. He is really hoping
that he will get drafted over this next year
into the NLB draft, and he would like to fix
this problem before that.

6. Pain Hx
• He states that pain is worse with
running, squatting, stretching and lifting
weights.
• He has tried Advil and icing which have been
somewhat helpful. He has not tried any
physical therapy. He has never had an
injection in the hip.
• He does report some clicking and popping in
the hip.

7. Back and Radiation Hx
• He denies any history of low back pain.
Denies any numbness or tingling in the legs.
Denies any radiating pain.

8. Summary
Age and Gender 17y male Sport Basketball
Duration of Pain 6 months Football
Unilateral Pain Yes Baseball (on scholarship)
Onset of pain Insidious
Pain ↑ running, squatting,
Traumatic Injury No stretching and lifting
weights
Physical Therapy No
Pain ↓ Advil and ice were
Medications None
somewhat helpful
Previous Injection No
Clicking and Popping Yes - Unilateral
Back Pain No
Pain Radiation No

9. Pain Location
• C-Sign
• Groin
• Grater Trochanteric
• Posterior

10. PHYSICAL EXAMINATION
Right Left (painful side)
Trendelenburg N N
Psoas Strength 5 4+
ROM - Flexion 110 100
Internal Rotation 15 5
External Rotation 20 40
Impingement Test + +
Labral Stress Test + + w/ click
FABER 2¼ 2+
Internal Snapping N N
Trochanteric Pain / Ober N N

11. Hip Joint Physical Examination
Physical Examination Video On YouTube

12. Trendelenburg Test
• Described by German
surgeon Friedrich
Trendelenburg in 1895.
• Positive result may
indicate weakness of
the abductors – mainly
the gluteus medius and
but also glut. minimus
and TFL

13. Iliopsoas Strength

14. Hip Flexion

15. Hip External Rotation

16. Hip Internal Rotation

17. Anterior Impingement Test (FADIR)

18. Labral Stress Test

19. FABER

20. Posterior Apprehension Test

21. Hyperextension External Rotation

22. Resisted Flexion (Stinchfield Test)

23. Internal Snapping

24. External Snapping and Ober Test

25. Athletic Pubalgia

26. Imaging

27. 1. Make sure it’s a good quality XR
2. Measurements
I. Joint space and arthritic changes
II. Cross-over sign
III. Os-acetabulum
IV. Profunda, protrosio
V. Center-edge angle and acetabular inclination

28. 34˚
X
90˚
1. Make sure it’s a good quality XR
2. Measurements
I. Joint space and arthritic changes
II. Cross-over sign
III. Os-acetabulum
IV. Profunda, protrosio
V. Center-edge angle and acetabular inclination

29. L
78˚ X
X

30. R

31. MRI

32. Reasons to do MRI
• To confirm the diagnosis
• Local anesthetics delivery
• Quantify pathology and morphology
• See peri-articular structures
– gluteus medius, iliopsoas tendon, peripheral compartment
• See areas that are hard to fully visualize during surgery
– Inferior acetabulum, Inferior/central femoral
head, Posterior and medial femoral neck
• See the bony pathologies –
– edema, AVN, sub-chondral cysts, tumors

35. Chondral Flap

36. Labral Damage – Intra-substance

37. Labral Tear Types
Seldes et al. (2001)
has recognized two
types of acetabular
labral tears:
Type 1 – Tear at the
base of the
chondro-labral
junction
Type 2 – Intra-
substance tear

38. Seldes I – Labral Detachment

39. Seldes II – Intra-substance Tear

40. Patho-Mechanism of Labral Tears
Cam impingement
 shear forces
 chondro-labral
damage (Seldes 1)

41. Patho-Mechanism of Labral Tears
Pincer Impingement
 compression
forces on the
labrum
 degeneration and
intrasubstance
tears (Seldes 2)

42. Pitt’s Pits - Herniation Pits

43. Iliopsoas Tendinitis
• Sagittal MR
imaging of a
professional male
tennis player
demonstrating
iliopsoas tendinitis
(white arrow) and
a posterior
perilabral cyst
(black arrow)

44. Sacral Stress Fracture
• MR imaging of a 21-
year-old female
collegiate volleyball
player presenting with
posterior hip pain and
negative radiographs.
MR imaging
demonstrates sacral
stress fracture (black
arrow) with
associated marrow
edema (white arrows)

45. Synovial Chondromatosis
• Coronal MR
imaging of a male
patient with cam
type FAI, and
multiple loose
bodies (arrows) of
synovial
chondromatosis.

46. Synovial Chondromatosis

47. Ischiofemoral Impingement

48. Hip Instability Following Dislocation

49. 3D CT

51. Local Anesthetic Injection

52. Intra-Articular Injection

53. Intra-Articular Injection
• 43% of patients, extra-articular structures may
be a major source of pain even though a labral
tear is suggested on MRI arthrogram
Intra-articular injection should be a
routine procedure

54. Dysplasia

55. What is Dysplasia?
• Wiberg described the lateral CE angle
• Defined thresholds:
– >25˚ as normal
– 25˚ to 20˚ as borderline normal
– <20˚ as dysplastic and pathologic

56. Dysplasia: Natural History
Lack of bony support
Increased load on hypertrophic labrum
Labral tearing
Antero-superior migration/subluxation
Eccentric loading of acetabular cartilage  ARTHRITIS

58. Parvizi 2009
• 34 arthroscopic labral debridements in
dysplastic hips
• Failed to relieve pain in 24 patients
• Accelerated arthritis in 14 patients
• Migration of the femoral head in 13 patients
• 16 patients underwent further surgery
– periacetabular osteotomy [6 patients]
– femoroacetabular osteoplasty [7 patients]
– total hip arthroplasty [3 patients]

59. Peri-Acetabular Osteotomy (PAO)
• Currently the ONLY surgical solution which
corrects the deformity
• Arthroscopic treatment should be considered
only if PAO is not an option

60. Acetabular Fragment Rotation
Ganz CORR 1988

61. PAO with Arthroscopy

62. 22 yo F, 2 years of R hip pain, MRI: Ant-sup labral tear
18˚
3˚
X X

63. 22 yo F, 2 years of R hip pain – Hip Arthroscopy

64. Labral Tears In Dysplasia
DO NOT RESECT THE LABRUM
Unless planning a labral reconstruction
The Labrum is important in:
– Absorption of loading forces
– Prevention of subluxation
– Risk in increasing instability and
subluxation after labrum resection

65. The Capsule in Dysplasia
• In dysplasia, instability is
the problem
• ALWAYS PRESERVE or
PLICATE THE CAPSULE
• Capsular plication may
allow improved
stability, diminish likelihood
of lateral migration

66. PAO – Treating the Underlying Problem

67. Cause - Effect
Underling
Problem Asymptomatic
Damage Pain

68. Intra-articular Pathologies
•Cam Structural
Underling Problem
•Pincer Damage
Pain Generators
•Dysplasia
•Perthes •Labral Tears
•SCFE •Chondral Damage
•High Femoral Anteversion •Synovitis
•Micro-Instability •Ligamentum Teres Tears
•Loose Bodies
•Iliopsoas Tendon Snapping
•PVNS Disease •Iliopsoas Bursitis
•Synovial Chondromatosis •Capsular Stress
•Arthritis
•Osteonecrosis
•Transient Osteoporosis
•Inflammatory Diseases

69. Extra-articular Hip Pain
Muscle/Tendon/Bursa Bone Nerve
• Adductors • Stress Fx • Lat Fem Cut
• ITB Syndrome • Epiphysitis • Genito femoral
• Iliopsoas Complex • Transient • Ilioinguinal
• Piriformis/Hip ERs Osteoporosis • Sciatic
• Gluteus Min/Med
• Hamstring Complex Other
• Sports Hernia
• Pelvic visceral
pain

70. The end