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HIP and SPINE Syndrome
One of the more challenging tasks for
clinicians is determining where lower extremity
pain originates -
The term hip-spine
syndrome has been
used to describe
osteoarthritis (OA) of
hip and degenerative
Introduced by Offierski and MacNab in 1983
Can also present with extremity pain and limitations in walking.
Most frequent indication for spinal surgery in persons aged >65 years.
Many types of lumbar stenosis –
• Degenerative (most frequently )
• Primary (ie, idiopathic) accounts for most cases
• Secondary (gout, chondrocalcinosis, and hemochromatosis)
Prevalence of radiographic hip OA is 27% in adults aged ≥45 years
Symptomatic hip OA is reported in 9.2% of adults aged≥45 years.
Thus one should correlate the radiographic findings with subjective
symptoms and physical examination findings consistent with hip
They categorized patients as
Pathologic changes exist in the hip
and lumbar spine, but only one clear
source of disability is present.
changes but with no
clear source of disability.
Pathologic processes are
interrelated, with each
exacerbating the other.
• Radiating pain involving the lower extremity is
common secondary to hip and spine
• Hip OA - groin and buttock pain, a limp,
referred knee pain, and pain with hip ROM
• Patients with groin pain have been shown to
be 7 times more likely to have a hip disorder
only or a hip plus-spine disorder than a spine-
• Symptomatic lumbar stenosis - neurogenic
claudication with back and lower extremity
pain that begins and worsens with ambulation
and is relieved with sitting.
• The pain often resolves or improves on
bending forward or sitting.
• The shopping cart sign - comfort ambulating
while leaning over a shopping cart.
• Groin pain is uncommon in patients with
• However, it can be the presenting complaint
with foraminal stenosis at the L1 or L2 level
• Lateral hip pain - diagnostic dilemma
– can be a common presenting complaint, with
radiation to the buttock and/or lower back region
and down the lateral leg
– May be secondary to greater trochanteric pain
syndrome, including bursitis and inflammation or
tear of the gluteal tendon.
– Lumbar pathology and primary hip OA can also
cause referred pain in this region
• Reproduction of the pain in the affected
extremity on weight bearing - consistent with
– Direct physical examination may elicit pain with
manipulation, including internal or external
rotation and log roll, antalgic gait
– Decreased hip ROM, which most commonly
presents as loss of internal rotation
– Cam and pincer impingement are evaluated with
the anteroposterior and posteroinferior
impingement tests (described later)
Physical examination findings are less
predictable in persons with spinal stenosis
– Minority of patients - radicular findings such as a
positive SLR or FNST, decreased reflexes;
diminished sensation, decreased strength with or
without muscle atrophy.
– A positive femoral tension sign is nearly five times
more likely to be noted in persons with lumbar
stenosis than in those with hip pathology only
• Plain radiography is the initial ancillary study
obtained in the workup of hip OA.
– Femoral and/or acetabular osteophytes
– Subchondral cysts
– Joint space narrowing on weight-bearing views.
• Cam or pincer impingement may be seen on
– Subchondral lucency in the femoral head, which
has the potential to progress to collapse and
deformation implies more advanced osteonecrosis
(can be visualized only on MRI)
– The labrum (often first structure to fail) is best
visualized on MRI arthrogram.
– MRI can also be helpful in ruling out an occult
femoral neck or pelvis fracture, infection, or tumor
as the cause of pain
• Fluoroscopically guided hip anesthetic
injections can help further elucidate the
primary pain generator
– Many studies have demonstrated that patients
who experience ≥50% pain relief following an
intraarticular hip injection are likely to have a
successful outcome following THA
• For pain that is primarily lateral, an injection
of the trochanteric bursa can be diagnostic
and frequently serves as definitive therapy.
– If injection and/or other empiric interventions (eg,
therapy, phonophoresis) do not provide pain
relief, imaging of the spine should be considered.
• In persons with suspected DLSS
– imaging typically begins with upright plain
radiographs, including AP, lateral, flexion, and
– MRI or CT myelography is used to identify neural
• Electrophysiologic studies are used when the
diagnosis remains unclear
– Findings of bilateral polyradiculopathy at multiple
levels can be suggestive of this
– Helpful in distinguishing neurologic changes of
spinal stenosis from either peripheral nerve
compression or diabetic peripheral neuropathy
• Fluoroscopically guided epidural steroid
– may be diagnostic or confirmatory
– Improvement in the primary symptoms following
ESI can help confirm stenosis as the primary pain
– However, lack of improvement following ESI does
not definitively rule out lumbar stenosis as the
D/d-Rule out other causes of lower
• Peripheral vascular disease
• Diabetic peripheral neuropathy
• Pelvic pathology - Sources of pain about the pelvis
are numerous. Labral tears of the hip, Painful osseous
pathology includes metastases, Paget disease, occult
hip fractures, insufficiency fractures of the sacrum,
• More lateral pain -secondary to greater trochanteric
bursitis or gluteal tendinitis /tendon ruptures.
• Vascular claudication
• Knee OA
• Knee OA is a common cause of lower
extremity pain, especially in the aging
• DLSS and hip OA can both present with
referred knee pain
• History, physical examination, and knee
D/d-Rule out other causes of lower
The value of bupivicaine hip injection in the
differentiation of coxarthrosis from lower extremity
Kleiner JB, Thorne RP, Curd JG.
A series of 18 consecutive patients with roentgenographically
proven osteoarthrosis of the hip and spine were evaluated
because of concomitant lower extremity pain below the knee.
• To determine whether the leg symptoms were coxalgic or
neuropathic, intraarticular hip bupivicaine was injected as
a provocative test.
• This test allowed correct identification of the source of the
pain with a sensitivity of 87%, a specificity of 100%, and
an efficiency of 88%.
• This office test also provides significant savings in terms of
diagnostic tests and patient discomfort.
Results from several studies have shown that, in the presence of
concomitant disease, treatment of the spine does not alleviate
pain in patients with hip arthritis, and vice versa
reporting on patients
with concomitant hip
and spinal disease,
found that most who
underwent THA followed
More prudent in
the presence of
spinal stenosis to
treat the spinal
condition first, as
there is a risk for
McNamara MJ, Barrett KG,
Christie MJ, Spengler DM.
Lumbar spinal stenosis and
lower extremity arthroplasty.
Brown MD, Gomez-Martin
O, Brookfield KF, Li PS.
Differential diagnosis of
hip disease versus spine
disease. Clin Orthop.
• Femoroacetabular impingement (previously
“acetabular rim syndrome” or
• Major cause of early osteoarthritis of the hip,
especially in young and active patients
• It is characterized by an early pathologic
contact during hip joint motion between
skeletal prominences of the acetabulum and
the femur that limits the physiologic hip ROM,
typically flexion and internal rotation.
Depending on clinical and
Two types of impingement
1. Pincer impingement is the acetabular cause of
FAI and is characterized by focal or general
overcoverage of the femoral head.
2. Cam impingement is the femoral cause of FAI
and is due to an aspherical portion of the
femoral head–neck junction
3. Most patients (86%) have a combination of both
called “mixed pincer and cam impingement,”
with only a minority (14%) having the pure FAI
(A) In “cam” FAI, there is decreased
offset at the femoral head/neck
(B) With flexion and internal rotation,
this aspherical portion of the
femoral head produces shear
forces at the cartilage/labrum
transition zone causing damage
to the peripheral cartilage
(C) In “pincer” FAI, there is a local or
global acetabular overcoverage.
(D) As the hip is flexed the femoral
neck abuts the anterosuperior
acetabualar rim, crushing the
The proposed mechanisms of
• Groin pain with hip rotation, in the sitting
position, or during or after sports activities.
• Describe a trochanteric pain radiating in the
• Typically, they are aware of their limited hip
mobility long before symptoms appear.
• Restricted ROM, particularly flexion and
• A positive impingement sign is present for
anterior FAI if the forced internal
rotation/adduction in 90°of flexion is
reproducibly painful, and for posterior
impingement with painful forced external
rotation in full extension
In extreme forms,
external rotation of
hip during hip flexion
sign is positive when
there is painful forced
external rotation in
is positive, with
internal rotation in
90° of flexion.
Diagnosis - Clinical
• Insidious onset of groin pain caused by
repetitive impingement between the
acetabulum rim and femoral head-neck
• Initially the pain is intermittent
• Exacerbated by high demand activities that
require forceful hip flexion and internal
Diagnosis - Clinical
• Pincer-type more common in women
• often presents as activity-related groin pain
(caused by the innervated labrum being
crushed between the acetabular rim and
• This symptom often acts as a warning sign,
causing pincer-type patients to seek earlier mx
before significant chondral damage occurs
Diagnosis - Clinical
• Cam type- Deep and extensive chondral
lesions that are seen with cam-type
• More common in young males.
• Group has often developed significant
chondral injury by the evaluation time they
present for symptomatic
Correct setting for anteroposterior and strong lateral (left) pelvic
radiography. Cross-table axial radiograph of hip (right) is needed
to visualize anatomy of anterior femoral head–neck junction,
which is not visible on anteroposterior pelvic radiograph.
• The next step in assessment should evaluate
for pincer-type which can occur as a result of
either global or local overcoverage of the
• A femoral head or medial acetabular wall that
is medial to Kohler’s line is characteristic for
protrusio acetabuli and coxa profunda
• The anterior and posterior acetabular walls
should then be outlined. These lines should
maintain a separation throughout their entire
• Overlap of the anterior and posterior walls at
the superolateral margin of the acetabulum is
called a “crossover sign”
• The next step - assess for cam FAI
• Given its anterosuperior location, it is
underappreciated on a standard AP
radiograph and may be obstructed by the
greater trochanter on a frog-leg lateral view.
• The aspherical head-neck junction is best
visualized on either Dunn view or a cross-table
lateral view with the leg in 15°of IR
• The Dunn view, it is an anteroposterior view of
the hip with the patient supine and with the
hips and knees flexed at 90°, the legs
abducted 15°-20° from the midline, and
the femur in neutral rotation.
The internally rotated cross-
table lateral view is often more
practical for routine use,
because positioning for the
Dunn view requires a leg holder
Radiographic evaluation - General
• Normally, general acetabular overcoverage is
correlated with the radiologic depth of the
• A normal hip appears on an AP pelvic
radiograph with the acetabular fossa line lying
laterally to the ilioischial line
– Coxa profunda = floor of the fossa acetabuli
touching or overlapping the IIL medially.
– Protrusio acetabuli = femoral head is overlapping
the IIL medially
Coxa profunda - Acetabular fossa (F) is touching or overlapping
ilioischial line (IIL). A' = covered portion of the femoral head, E' =
uncovered portion of the femoral head.
Protrusio acetabuli Femoral head line (H) is crossing
ilioischial line (IIL)
Radiographic evaluation - Focal
• Focal overcoverage can occur in the anterior
or the posterior part of the acetabulum.
• Anterior overcoverage is called “cranial
acetabular retroversion” or “anterior focal
acetabular retroversion” and causes anterior
FAI that can be reproduced clinically with
painful flexion and internal rotation.
• A normal acetabulum is anteverted and has
the anterior rim line projected medially to the
posterior wall line
• A focal overcoverage of the anterosuperior
acetabulum causes a cranially retroverted
• Anterior rim line being lateral to the posterior
rim in the cranial part of the acetabulum and
crossing the latter in the distal part of the
acetabulum. This figure-8 configuration is
called the “cross-over” sign
Radiographic evaluation - Focal
Focal anterior overcoverage of hip
Acetabular retroversion is defined as anterior wall (AW) being more
lateral than posterior wall (PW), whereas in normal hip anterior wall lies
This cranial acetabular retroversion can also be described by figure-8
• Magnetic resonance (MR) arthrogram with
– to determine the extent of existing cartilage injury
– assess for labral pathology
– subtle signs of impingement such as fibrocystic
changes at the head neck junction, formerly
named herniation pits
• CT can be used as adjunct to assess for
Non operative management
1. Activity modifications
2. Short course of NSAIDs - symptomatic relief in the acute
setting, however, their long-term use may mask the
symptoms of FAI despite progressive labral and chondral
3. Physical therapy may have a role by improving core and
hip flexor strength.
Nevertheless, restricted motion in FAI is due to an abnormal
bony morphology. Attempts to improve PROM are often not
beneficial and may be counterproductive.
Arthroscopic hip surgery
– symptomatic patient
– mechanical symptoms
recent literature supports arthroscopy shows
equivalent results to open hip surgery
open surgical hip dislocation
– gold standard for management of FAI if clinical
signs and structural evidence of impingement and
preserved articular cartilage, correctable
deformity, reasonable expectations
– age >55, morbid obesity, advanced joint disease
– structural deformity of acetabulum with poor
coverage of femoral head
– osteotomy and fixation
total hip arthroplasty
– age >60 years and end-stage hip degeneration