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Hip internal rotation is correlated to radiographic findings of cam femoroacetabular impingement in collegiate football players.Kapron AL, Anderson AE, Peters CL, Phillips LG, Stoddard GJ, Petron DJ, Toth R, Aoki SK.Arthroscopy. 2012 Nov;28(11):1661-70. doi: 10.1016/j.arthro.2012.04.153. Epub 2012 Sep 19.Department of Bioengineering, University of Utah, Salt Lake City, USA
Very sensitive test, may elicit pain in a subtle hip pathology. Not specific for impingement!
May be painful in posterior impingement or adhesive capsulitis (and restricted). May be minimal with anterior capsule laxity.
Cause compressive forces multiple times the body weight in the hip joint (Byrd). When compared to intra-articular injection, was found to be the most specific test for internal hip pain, FABER and labral stress test were found to be the most sensitive [PM&R 2010 http://www.ncbi.nlm.nih.gov/pubmed/20359681]
The limb is supported, as it is moved back and forth an external snap may be elicited. In Ober test - lowering the knee towards the table can assess ITB tightness.
* Inclusion and jamming of a proximal femoral deformity into the acetabulum (Cam type)*chondral and labral damage at the transitional zone
Direct impaction of the femoral neck against the acetabular rim (Pincer type)
Herniation pits were first described by Pitt in 1982, and were believed to be inclusion cysts that were normal variants and of no significance. Subsequently, Leunig and colleagues showed that 33% of patients undergoing surgery for FAI demonstrated herniations pits, and these occurred in the location of the impingement
Axial MR imaging demonstrating edema of the quadratus femoris muscle (arrow), consistent with the diagnosis of ischiofemoral impingement.
Axial MR imaging of a 19-year-old competitive soccer player who sustained a dislocation to his hip 3 years prior and continues to complain of hip instability without recurrent dislocation. Thickening and scarring of the iliofemoral ligament (arrows) is seen on MR imaging
More than 50% relieve of less.
Arthrsocopy 2008This study found that in 43% of individuals, extra-articular structures may be a major source of pain even though a labral tear is suggested on MRI arthrogram. Labral tear on MRI may not be the main source of pain, intra-articular injection should be a routine procedure.
Internal causes of hip pain - Itamar Botser, MD
Causes of Internal Hip PainDifferential Diagnosis and How to Diagnose Itamar Botser
Cause - EffectUnderlingProblem AsymptomaticDamage Pain
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.
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.
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.
Back and Radiation Hx• He denies any history of low back pain. Denies any numbness or tingling in the legs. Denies any radiating pain.
SummaryAge and Gender 17y male Sport BasketballDuration of Pain 6 months FootballUnilateral Pain Yes Baseball (on scholarship)Onset of pain Insidious Pain ↑ running, squatting,Traumatic Injury No stretching and lifting weightsPhysical Therapy No Pain ↓ Advil and ice wereMedications None somewhat helpfulPrevious Injection NoClicking and Popping Yes - UnilateralBack Pain NoPain Radiation No
PHYSICAL EXAMINATION Right Left (painful side)Trendelenburg N NPsoas Strength 5 4+ROM - Flexion 110 100 Internal Rotation 15 5 External Rotation 20 40Impingement Test + +Labral Stress Test + + w/ clickFABER 2¼ 2+Internal Snapping N NTrochanteric Pain / Ober N N
Hip Joint Physical ExaminationPhysical Examination Video On YouTube
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
1. Make sure it’s a good quality XR2. Measurements I. Joint space and arthritic changes II. Cross-over sign III. Os-acetabulum IV. Profunda, protrosio V. Center-edge angle and acetabular inclination
34˚ X 90˚1. Make sure it’s a good quality XR2. Measurements I. Joint space and arthritic changes II. Cross-over sign III. Os-acetabulum IV. Profunda, protrosio V. Center-edge angle and acetabular inclination
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
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
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
Dysplasia: Natural History Lack of bony support Increased load on hypertrophic labrum Labral tearing Antero-superior migration/subluxationEccentric loading of acetabular cartilage ARTHRITIS
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]
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
22 yo F, 2 years of R hip pain, MRI: Ant-sup labral tear 18˚ 3˚ X X
22 yo F, 2 years of R hip pain – Hip Arthroscopy
Labral Tears In DysplasiaDO NOT RESECT THE LABRUMUnless planning a labral reconstructionThe Labrum is important in: – Absorption of loading forces – Prevention of subluxation – Risk in increasing instability and subluxation after labrum resection
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