Causes of Internal Hip PainDifferential Diagnosis and How to Diagnose              Itamar Botser
Cause - EffectUnderlingProblem                AsymptomaticDamage                       Pain
Intra-articular Pathologies                    •Cam StructuralUnderling Problem                    •Pincer                ...
HISTORY OF PRESENT ILLNESS:• 17-year-old gentleman who complains of left  hip pain for the last 6 months.• He denies any i...
Sport• He plays basketball and football, and recently  received a full scholarship to Santa Clara  University for baseball...
Pain Hx• He states that pain is worse with  running, squatting, stretching and lifting  weights.• He has tried Advil and i...
Back and Radiation Hx• He denies any history of low back pain.  Denies any numbness or tingling in the legs.  Denies any r...
SummaryAge and Gender         17y male           Sport    BasketballDuration of Pain       6 months                    Foo...
Pain Location•   C-Sign•   Groin•   Grater Trochanteric•   Posterior
PHYSICAL EXAMINATION                            Right   Left (painful side)Trendelenburg                N              NPs...
Trendelenburg Test• Described by German  surgeon Friedrich  Trendelenburg in 1895.• Positive result may  indicate weakness...
Iliopsoas Strength
Hip Flexion
Hip External Rotation
Hip Internal Rotation
Anterior Impingement Test (FADIR)
Labral Stress Test
FABER
Posterior Apprehension Test
Hyperextension External Rotation
Resisted Flexion (Stinchfield Test)
Internal Snapping
External Snapping and Ober Test
Athletic Pubalgia
Imaging
1. Make sure it’s a good quality XR2. Measurements    I. Joint space and arthritic changes    II. Cross-over sign    III. ...
34˚                                                  X                         90˚1. Make sure it’s a good quality XR2. Me...
L    78˚   XX
R
MRI
Reasons to do MRI•   To confirm the diagnosis•   Local anesthetics delivery•   Quantify pathology and morphology•   See pe...
Chondral Flap
Labral Damage – Intra-substance
Labral Tear TypesSeldes et al. (2001)  has recognized two  types of acetabular  labral tears:  Type 1 – Tear at the  base ...
Seldes I – Labral Detachment
Seldes II – Intra-substance Tear
Patho-Mechanism of Labral TearsCam impingement shear forces chondro-labral  damage (Seldes 1)
Patho-Mechanism of Labral TearsPincer Impingement compression   forces on the   labrum degeneration and   intrasubstance...
Pitt’s Pits - Herniation Pits
Iliopsoas Tendinitis• Sagittal MR  imaging of a  professional male  tennis player  demonstrating  iliopsoas tendinitis  (w...
Sacral Stress Fracture• MR imaging of a 21-  year-old female  collegiate volleyball  player presenting with  posterior hip...
Synovial Chondromatosis• Coronal MR  imaging of a male  patient with cam  type FAI, and  multiple loose  bodies (arrows) o...
Synovial Chondromatosis
Ischiofemoral Impingement
Hip Instability Following Dislocation
3D CT
Local Anesthetic Injection
Intra-Articular Injection
Intra-Articular Injection• 43% of patients, extra-articular structures may  be a major source of pain even though a labral...
Dysplasia
What is Dysplasia?• Wiberg described the lateral CE angle• Defined thresholds:  – >25˚ as normal  – 25˚ to 20˚ as borderli...
Dysplasia: Natural History                Lack of bony support       Increased load on hypertrophic labrum                ...
Parvizi 2009• 34 arthroscopic labral debridements in  dysplastic hips• Failed to relieve pain in 24 patients• Accelerated ...
Peri-Acetabular Osteotomy (PAO)• Currently the ONLY surgical solution which  corrects the deformity• Arthroscopic treatmen...
Acetabular Fragment Rotation              Ganz CORR 1988
PAO with Arthroscopy
22 yo F, 2 years of R hip pain, MRI: Ant-sup labral tear                                          18˚          3˚         ...
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:  – Abs...
The Capsule in Dysplasia• In dysplasia, instability is  the problem• ALWAYS PRESERVE or  PLICATE THE CAPSULE• Capsular pli...
PAO – Treating the Underlying Problem
Cause - EffectUnderlingProblem                AsymptomaticDamage                       Pain
Intra-articular Pathologies                    •Cam StructuralUnderling Problem                    •Pincer                ...
Extra-articular Hip PainMuscle/Tendon/Bursa    Bone             Nerve• Adductors            • Stress Fx      • Lat Fem Cut...
The end
Internal causes of hip pain - Itamar Botser, MD
Internal causes of hip pain - Itamar Botser, MD
Internal causes of hip pain - Itamar Botser, MD
Internal causes of hip pain - Itamar Botser, MD
Internal causes of hip pain - Itamar Botser, MD
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Internal causes of hip pain - Itamar Botser, MD

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

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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

    1. 1. Causes of Internal Hip PainDifferential Diagnosis and How to Diagnose Itamar Botser
    2. 2. Cause - EffectUnderlingProblem AsymptomaticDamage Pain
    3. 3. Intra-articular Pathologies •Cam StructuralUnderling 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. 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. 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. 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. 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. 8. 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
    9. 9. Pain Location• C-Sign• Groin• Grater Trochanteric• Posterior
    10. 10. 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
    11. 11. Hip Joint Physical ExaminationPhysical Examination Video On YouTube
    12. 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. 13. Iliopsoas Strength
    14. 14. Hip Flexion
    15. 15. Hip External Rotation
    16. 16. Hip Internal Rotation
    17. 17. Anterior Impingement Test (FADIR)
    18. 18. Labral Stress Test
    19. 19. FABER
    20. 20. Posterior Apprehension Test
    21. 21. Hyperextension External Rotation
    22. 22. Resisted Flexion (Stinchfield Test)
    23. 23. Internal Snapping
    24. 24. External Snapping and Ober Test
    25. 25. Athletic Pubalgia
    26. 26. Imaging
    27. 27. 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
    28. 28. 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
    29. 29. L 78˚ XX
    30. 30. R
    31. 31. MRI
    32. 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
    33. 33. Chondral Flap
    34. 34. Labral Damage – Intra-substance
    35. 35. Labral Tear TypesSeldes 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
    36. 36. Seldes I – Labral Detachment
    37. 37. Seldes II – Intra-substance Tear
    38. 38. Patho-Mechanism of Labral TearsCam impingement shear forces chondro-labral damage (Seldes 1)
    39. 39. Patho-Mechanism of Labral TearsPincer Impingement compression forces on the labrum degeneration and intrasubstance tears (Seldes 2)
    40. 40. Pitt’s Pits - Herniation Pits
    41. 41. Iliopsoas Tendinitis• Sagittal MR imaging of a professional male tennis player demonstrating iliopsoas tendinitis (white arrow) and a posterior perilabral cyst (black arrow)
    42. 42. 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)
    43. 43. Synovial Chondromatosis• Coronal MR imaging of a male patient with cam type FAI, and multiple loose bodies (arrows) of synovial chondromatosis.
    44. 44. Synovial Chondromatosis
    45. 45. Ischiofemoral Impingement
    46. 46. Hip Instability Following Dislocation
    47. 47. 3D CT
    48. 48. Local Anesthetic Injection
    49. 49. Intra-Articular Injection
    50. 50. 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
    51. 51. Dysplasia
    52. 52. 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
    53. 53. Dysplasia: Natural History Lack of bony support Increased load on hypertrophic labrum Labral tearing Antero-superior migration/subluxationEccentric loading of acetabular cartilage  ARTHRITIS
    54. 54. 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]
    55. 55. 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
    56. 56. Acetabular Fragment Rotation Ganz CORR 1988
    57. 57. PAO with Arthroscopy
    58. 58. 22 yo F, 2 years of R hip pain, MRI: Ant-sup labral tear 18˚ 3˚ X X
    59. 59. 22 yo F, 2 years of R hip pain – Hip Arthroscopy
    60. 60. 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
    61. 61. 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
    62. 62. PAO – Treating the Underlying Problem
    63. 63. Cause - EffectUnderlingProblem AsymptomaticDamage Pain
    64. 64. Intra-articular Pathologies •Cam StructuralUnderling 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
    65. 65. Extra-articular Hip PainMuscle/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
    66. 66. The end

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