Transcript Modern Hip-Hop

By Dr Tom Crisp
Clinical Director Bupa MSK Services
Senior Lecturer Queen Mary University London
Saturday 1st December 2012
Outline
 Diagnosing Hip problems
 Management
 Practical sessions
History Taking
The difference between a good
and indifferent clinician is the
time spent on history taking
Sir Farquahar Buzzard 1933
Aspects of history
 Hip pain is usually felt in groin
 Mechanical symptoms may imply
labral pathology
 Degeneration is usually associated
with pain after exercise and after
inactivity
Examination
 Essential to an accurate diagnosis or at least
differential
 Exclude other causes
 Starts with examination of spine
 Pelvic stability
 Trendelenberg Test
Examination
 Range of movement
 Flexion, Extension
 Abduction and adduction
 Int and ext rotation – neutral and flexed
 FABER and other combinations
 Quadrant testing
 Muscle function multiple positions,
 Neurological tests
Osteo-arthritis
 Previously disease of middle age or later
 Presenting earlier
 Not uncommon in 40’s
 May be associated with (silent) SPFE
Differential diagnosis
 FAI
 Labral tears
 OA
 Inflammatory arthritis
 Non arthrogenic causes inc referred pain
FAI
 Recent diagnosis
 Overdiagnosed
 Associated with labral tears and OA
 Evident on x-ray
 MRI (esp STIR) shows stress and therefore possibly
clinical relevance
 Should be known as FADeformity
FAI
 Like all impingement has a contribution from soft
tissues
 Does not necessarily require surgery
 Cam and pincer types
C Sign
 Points to groin with fingers
 May also radiate laterally
from groin
Examination
 ROM
 FABER
 FADIR
 Quadrant/grind
F
A
D
I
R
Investigation
 X-ray – PA or Dunn View
 FLEXED TO 90 and 20 abducted
 MRI
 MRA – indirect or direct?
 Direct 85% sensitivity 50-70% specificity for labral tears
 J Bone Joint Surg Am. 2012 Aug 8. Reliability and Validity of
Diagnosing Acetabular Labral Lesions with Magnetic
Resonance Arthrography.Reurink G, Jansen SP, Bisselink
JM, Vincken PW, Weir A, Moen MH
 LA Injection
 2 birds with one stone!
Cam Type
Pincer Type (Dunn View)
Management
 Physiotherapy
 Activity modification
 Pelvic stability
 Investigation
 Consider steroid injection and MRA
 Surgery if failure of conservative treatment
Labral Tears
 May be associated with impingement
 Often non-specific symptoms
 Maybe asymptomatic
Asymptomatic volunteers
 Am J Sports Med. 2012 Oct 25. Prevalence of Abnormal





Hip Findings in Asymptomatic Participants: A
Prospective, Blinded Study.Register B, Pennock AT,
Ho CP, Strickland CD, Lawand A, Philippon MJ
69% of hips had labral tears (45 subjects aged 15-55)
24% Chondral defects
11% acetabular oedema
16% subchondral cysts
20% “osseous bumps”
Asymptomatic volunteers
 More over 35yrs
 x13.7 for chondral defects
 Males had x 8.5 osseous bumps than females
 Treat symptoms and clinical situation not imaging!
 Hip arthroscopy causes worsening in 10% patients
 What are the long term consequences of ignoring
changes??
Labral tears
 Arthroscopy. 1996 Oct;12(5):603-12.Labral lesions: an
elusive source of hip pain case reports and
literature review.Byrd JW.
 Diagnosis should be confirmed by
fluoroscopically guided local anaesthetic
injection
Non-surgical treatment of OA
 Physiotherapy/Rehabilitation
 Muscle balance and flexibility
 Pelvic stability
 Injection
 Delay arthroplasty
 Symptomatic treatment alone may increase load and
so treatment must address pre-disposing factors.
 Pain not linked to pathology but possibly to
prognosis?
Non-surgical treatment of OA
 Treat pain
 Normalise function
 Build muscle
 Allow ADL’s
 No necessity to avoid surgery but sense to use least
invasive approach first
Management in Young
 Consider differential
 Stress fracture
 Ischaemic necrosis
 Non-arthrogenic causes
 Consider surgical (non-arthroplasty) solutions
 Athroscopy
 Microfracture
Injections
 Reduce pain and thus improve function
 Can produce long term (6-12month) improvement
 No evidence that surgical solutions such as
microfracture produce longer term benefits
 Steroids useful
 Visco-supplementation beneficial but little direct
evidence as yet.
 Even less evidence for PRP!