By Dr Tom Crisp Clinical Director Bupa MSK Services Senior Lecturer Queen Mary University London Saturday 1 st 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 FADIRFADIR

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 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 MHReurink 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 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 MJRegister 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 Oct;12(5): Labral lesions: an elusive source of hip pain case reports and literature review.Byrd JW.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!