Meg Pusateri, MD Brandon Hockenberry, MD Approach to Hip Pain Meg Pusateri, MD Brandon Hockenberry, MD

Objectives Anatomy Review Key Questions Differential Diagnosis Physical Exam Pathology

KEY QUESTIONS: Approach to Hip Pain 1. History? Adult vs. Peds? Activities/Sports? 2. Is this actually the hip? Back? Knee? 3. Intra-articular vs. extra-articular? 4. Exam maneuvers? 5. Differential? Approach to Hip Pain

Differential Diagnosis Lateral Femoral Cutaneous Intraarticular Piriformis Syndrome Intra or Extraarticular Osteoarthritis Labral Tear Fractures FAI (Femoral Acetabular Impingement) Stress Fracture Avulsion Fracture Osteonecrosis (AVN) Snapping Hip/IT Band Syndrome Extraarticular Malignancy Soft Tissue Injury Infection Contusion Septic Joint (Hip, SI) Sprain Osteomyelitis Tendonitis Pediatrics Athletic Pubalgia/Sports Hernia Osteitis Pubis Legg-Calve-Perthes Disease Greater Trochanteric Pain Syndrome SCFE (Slipped Capital Femoral Epiphysis) Nerve Entrapments Apophysitis Obturator Transient Synovitis Differential Diagnosis

Inspection Erythema, edema, wounds, gross deformity, etc. Leg Length Internally/externally rotated? Gait Antalgic? Trendelenberg? Inspection

Palpation Greater Trochanter/Bursa Anterior Superior Iliac Spine (ASIS) Ischial Tuberosity Iliac Crest Iliotibial Band/TFL Pubic Symphysis Palpation

Range of Motion Flexion: 120-130o Extension: 10-20o Abduction: 40-50o Adduction: 20-30o Internal Rotation: 30-40o External Rotation: 40-50o

Special Tests FADIR FABER or Patrick’s Test Log Roll Test Ober’s Test Flexed, ADducted, and Internally Rotated Hip/groin pain = positive Possible labral tear, FAI FABER or Patrick’s Test Flexed, ABducted, and Externally Rotated Hip or back pain = positive Intraarticular lesions vs. iliopsoas pain vs. SI joint Log Roll Test Ober’s Test Often measured in “fists” Tight ITB Stinchfield’s Test Resisted straight leg raise Labral Grind Special Tests

Other Exam Considerations Neurovascular Exam Pulses Sensory Strength Reflexes Back/Spine Exam Knee Exam Other Exam Considerations

Osteoarthritis Hip OA: 88/100,000 per year vs. Knee OA 240/100,000 per year Risk Factors: Articular trauma Muscle weakness High impact sports Heavy, physical labor Gender, female > male Increasing age Developmental abnormalities (ex: SCFE)

Femoro-acetabular Impingement (FAI) Occurs due to impingement of the femoral head against the anterior edge of the acetabulum CAM vs. Pincer lesion CAM more common in young, active males Pincer more common in active, middle age women 70-80% have a mixed lesion Can cause secondary osteoarthritis, labral degeneration/tears, and cartilage damage/tears. Femoro-acetabular Impingement (FAI)

Femoro-acetabular Impingement (FAI) Among athletes, often seen among those who regularly perform movements that force the femoral head anteriorly, like hyperextension/flexion. Ice Hockey Soccer Treatments include: Observation Physical Therapy Intraarticular Injection Surgery

Snapping Hip 3 Types: External Snapping Hip Internal Snapping Hip ITB sliding over greater trochanter. Often visible, palpate trochanter as hip flexed Internal Snapping Hip Most common Reproduced by moving hip from an externally rotated/flexed position to an externally rotated/extended position. Intra-articular Snapping Hip Loose bodies Labral Tears Snapping Hip

https://www.youtube.com/watch?v=ZPunNixL1oU

Greater Trochanteric Pain Syndrome Chronic regional pain caused by a combination of both gluteal tendon injuries and bursitis  Previously, trochanteric bursitis was seen as the main pain source, but recent research indicates that bursitis is only seen in the minority Can be caused by: Direct trauma (ex: fall onto your side) Prolonged pressure to the hip area Repetitive movements (ex: walking/running) Unaccustomed vigorous exercise Weight-bearing on the one leg for long periods Hip instability Greater Trochanteric Pain Syndrome

Greater Trochanteric Pain Syndrome Lateral hip pain per history and exam NOT intraarticular All of the following attach on the greater trochanter: 1. Gluteus Maximus 2. Gluteus Medius 3. Gluteus Minimus 4. Tensor Fascia Latae Greater Trochanteric Pain Syndrome