HIP msk conditions 

Intra-articular Hip Pain

1. Primarily presents in the anterior region in young adults.
2. Aggravation by hip flexion or rotation should prompt evaluation for intra-articular pathologies.
3. Anterior hip pain can stem from
   • hip flexor strains, tears
   • avulsion fractures
4. often has a sports-related or traumatic incident background.
5. Differential diagnosis also includes referred pain from abdominal issues
   • gastrointestinal causes
   • appendicitis
   • hernia
   • bladder
   • female reproductive system

Femoroacetabular Impingement (FAI)

• A common cause of hip pain in young adults.
• Often presents gradually without specific injury, more quickly in athletes, and is particularly problematic for activities requiring extensive hip motion. 
• subtle deformities in hip shape that cause impingement between the femoral neck and anterior rim of the acetabulum during the normal range of functional hip movement, particularly in flexion adduction and internal rotation. 
• The impinging surfaces can irritate and damage the soft tissues of the hip joint of which most at risk are the acetabular labrum and the adjacent acetabular cartilage. 
• Hip shape deformities are classified into three types: 
• • cam type – asphericity of the femoral head; widening of the femoral neck. The term comes from the cam-lobes on engine cam-shafts, which open and close valves by impinging on the appropriate surface as they rotate
  • pincer type – over coverage of the anterosuperior acetabular wall; a deep socket. Similar to the tips of pincer forceps
  • mixed type – a combination of cam and pincer deformities.
• Cam impingement is more common in young men, and pincer in middle-aged women. 
• Symptoms
  • common symptoms
    • activity related groin or hip pain, exacerbated by hip flexion
    • difficulty sitting
    • mechanical hip symptoms of clicking or popping
    • can present with gluteal or trochanteric pain
      • due to aberrant gait mechanics
• Exam
  • motion
    • limited hip flexion (<90 degrees), especially with internal rotation (<5 degrees)
    • anterior impingement test (flexion, adduction, internal rotation) elicits pain     
    • 
• inspection
  • externally rotated extremity
    • can be due to post-SCFE deformity
• Differential
  • Ischiofemoral impingement     
  • adductor strains and athletic pubalgia  
  • lumbar radiculopathy
  • iliopsoas pathology
  • hip instability

Conservative Management for Femoroacetabular Impingement (FAI) Syndrome

• Improve neuromuscular function of the hip due to weakness of deep hip musculature.
• Enhance dynamic stability of the hip joint.

Recommendations

1. Hip-Specific and Functional Lower Limb Strengthening:
   • Focus on deep hip external rotators, abductors, and flexors.
   • Train in the transverse, frontal, and sagittal planes.
2. Core Stability:
   • Strengthen core muscles to support overall hip stability.
3. Postural Balance Exercises:
   • Improve balance and postural control to aid hip function.

Evidence from Randomised Controlled Trial

• Mansell et al. Study:
  • Compared surgical intervention versus physiotherapy for FAI syndrome.
  • No statistically significant difference in outcomes between surgical and non-surgical groups.
  • On average, subjects in both groups reported no improvement in their condition at the two-year follow-up.

Surgical Procedure

• May include labral repair or debridement.
• Trimming of the acetabular rim and/or femoroplasty, as determined by the surgeon.

Physiotherapy Protocol

• Tailored to Each Subject Based on Standardised Assessment:
  • Manual Therapy: Techniques to improve joint mobility and reduce pain.
  • Motor Control Exercises: Exercises to enhance motor control and coordination.
  • Mobility/Stretching Exercises: Improve flexibility and range of motion.

Surgery with a Post-Operative Physiotherapy Programme

• Sessions:
  • One pre-operative session.
  • Six post-operative 30-minute sessions.
  • Post-operative sessions were two weeks apart, ending at 12 weeks.
• Treatment Components:
  • Education: On post-surgical care and rehabilitation.
  • Manual Therapy:
    • Mandatory release of key trigger points.
    • Optional lumbar mobilization.
  • Functional and Sport-Specific Drills:
    • Starting at 6-8 weeks post-surgery.
    • Training within the patient’s normal sport environment starting at 10-12 weeks post-surgery.
• Home Exercise Programme:
  • Daily exercises prescribed by the physiotherapist.
  • Included in the exercise sheet provided to patients.
• Unsupervised Gym and Aquatic Programme:
  • At least twice per week.
  • Activities include:
    • Pool walking
    • Stationary bike
    • Cross-trainer
    • Swimming
    • Lower body resistance exercises

Summary of the Protocol

1. Pre-Operative Session:
   • Education and baseline assessments.
2. Post-Operative Sessions:
   • Weeks 1-2: Education, manual therapy.
   • Weeks 3-6: Continued manual therapy, introduction of gentle exercises.
   • Weeks 6-8: Begin functional and sport-specific drills.
   • Weeks 10-12: Training within the normal sport environment.
3. Daily Home Exercise Programme:
   • Followed according to the exercise sheet provided.
4. Unsupervised Gym and Aquatic Programme:
   • To be performed at least twice per week.

Labral Tears

• May present with anterior hip pain, often related to sports injuries or repetitive motions.
• Symptoms
  • popping/catching sounds in activities like dance, gymnastics, hockey.
  • may have vague groin pain
  • may be associated with a sensation of locking
• Physical exam
  • provocative tests
    • anterior labral tear
      • pain if hip is brought from a fully flexed, externally rotated, and abducted position to a position of extension, internal rotation, and adduction  
    • posterior labral tear
      • pain if hip is brought from a flexed, adducted, and internally rotated position to one of abduction, external rotation, and extension.
• Initial imaging with a standing radiograph; advances in MRI technology (3-tesla) provide high sensitivity and specificity.
• Labral tears often coexist with FAI, especially in athletic patients.

Femoral Neck Stress Fractures

• Typically related to overuse, more prevalent in women, associated with energy imbalances in athletes.
• Early detection is crucial to prevent progression to a complete fracture.
• Not always visible on radiographs in early stages; MRI is required for a definitive diagnosis.

Avascular Necrosis

• Commonly seen in middle-aged to older adults.
• More common in men than women (ratios range from 3:1 to 5:1).
• Average age at treatment: 33-38 years.
• Sickle cell disease-related cases more prevalent in African descent.
• causes
  • Traumatic Causes:
    • Femoral neck fracture or dislocation of the femoral head from acetabulum can disrupt blood supply, leading to avascular necrosis.
    • Osteonecrosis occurs in 15-50% of femoral neck fractures and 10-25% of hip dislocations.
  • Non-Traumatic Causes:
    • Chronic steroid use and excessive alcohol consumption account for over 80% of non-traumatic cases.
    • Steroid-associated osteonecrosis is the second most common cause after trauma.
    • Pathophysiology includes fat emboli, fat cell hypertrophy, endothelial dysfunction, hyperlipidemia, and bone marrow stem cell abnormalities.
    • Alcohol-induced osteonecrosis likely involves similar mechanisms like fat cell hypertrophy and blood vessel occlusion.
  • Sickle Cell Disease:
    • Misshapen red blood cells impede blood flow, causing ischemia and osteonecrosis, especially in the femoral head.
  • Autoimmune and Chronic Inflammatory Disorders:
    • Conditions like systemic lupus erythematosus (SLE) are associated with femoral head osteonecrosis.
    • Often related to long-term steroid treatment, but can occur in steroid-naive patients.
  • Other Causes:
    • Legg-Calve-Perthes disease: Idiopathic avascular necrosis in children.
    • Vascular diseases secondary to diabetes and cytotoxic agents.
  • other risk factors
    • metabolic syndrome,
    • obesity.
• Early detection is crucial for joint preservation; MRI or CT is used for diagnosis.
• History and Physical:
  • Early stages often asymptomatic.
  • Symptoms:
    • Hip pain radiating to groin/thigh, worsened by activity, alleviated by rest.
  • Physical exam findings:
    • Restricted motion, pain upon abduction and rotation, hip tenderness.
• Evaluation:
  • Diagnosis via clinical presentation and imaging (x-rays, bone scanning, MRI).
  • MRI is the gold standard for diagnosis.
    • Steinberg staging system commonly used for classifying extent of necrosis.

Hip Fractures

• More frequent in older adults, often following a fall or in the context of osteoporosis.
• Examination reveals inability to walk, a shortened and externally rotated leg.
• Radiography is the primary diagnostic tool; surgical fixation is typically required.

Gluteus medius tendonitis

• Aka Dead Butt Syndrome (DBS)
• stiffness, pain and strength loss in the hip. 
• The pain typically worsens during weight-bearing exercise, including running, walking or climbing. 
• For many patients, the pain radiates down the thigh, similar to the symptoms of sciatica and hamstring tendinopathy

Avulsion bony injury

• Forceful contraction of muscles originating around the pelvis can lead to avulsion at their origin in those with skeletal immaturity:
  • ASIS (sartorius)
  • Anterior inferior iliac spine (long head rectus femoris)
  • Ischial tuberosity (hamstrings)
  • Lesser trochanter (psoas)
• Rx: Xray, referral, usually don’t need surgery

OA of the hip

• The most common cause of anterior hip pain in older adults.
• Severity of symptoms may not always correlate with radiographic findings.
• Characterized by
  • gradual onset, pain with prolonged sitting/walking
  • decreased range of motion.
• Diagnosed via standing anteroposterior radiography showing joint space narrowing, osteophyte formation.
• Rx:
  • In those with loss of function
  • THR in older pts
  • Most replacements last 15-20yrs
  • Some pts aged 30-40 also having surgery.

Entrapments: Obturator nerve entrapment 

• The obturator nerve :
  • Provides motor innervation to the medial compartment of the thigh 
• Compressive neuropathy of obturator nerve in patients with a well developed hip  adductor muscles
  • common in athletes, especially skaters
• Symptoms:
  • Pain & paresthesias may extend from hip to knee along the medial aspect of the thigh 
• Evaluation:
  • nerve conduction studies can help establish diagnosis
  • CT, MRI, or ultrasound imaging when intra-pelvic mass lesions are suspected of entrapping the nerve
• Treatment: nonoperative treatment indicated in most cases

Entrapments: piriformis syndrome

• Piriformis syndrome is a condition characterized by sciatic symptoms (leg pain) due to extrapelvic sciatic nerve compression at the hip. 
• Diagnosis is made clinically with pain in the posterior gluteal region and migrating down the back of the leg which is made worse with flexion, adduction, and internal rotation of hip.
• Symptoms
  • pain in the posterior gluteal region and migrating down the back of the leg
  • pain may be burning or aching in nature similar to sciatica symptoms
• Physical exam
  • FAIR test
    • Flexion, Adduction, and Internal Rotation of hip can reproduce symptoms  
    • maneuver places piriformis muscle on tension

Meralgia paraesthetica – Entrapment of LFCN (lateral femoral cutaneous nerve)

• Aka: Entrapment syndrome of lateral femoral cutaneous nerve (LFCN)
• Causes burning, numbness and paraesthesia down the proximal-anterolateral aspect of the thigh 
• Anatomy
  • LFCN
    • Entirely sensory (More detail in AFP article about location and course of this nerve) 
• Aetiology
  • Spontaneous, iatrogenic or traumatic
  • 20% of cases are bilateral
  • Iatrogenic cases are quite common especially as a complication of surgery around the ASIS (i.e. hernia repair)
• Mechanical factors:
  • External compression from tight trousers or belts
  • Conditions associated with increased intra-abdominal pressure (i.e. obesity, pregnancy)
  • Pelvic disease (causing a mass effect)
  • Hip abduction splints (for Perthes’ disease)
  • Entrapment by the fascia either proximal or distal to the ASIS
• Metabolic factors include diabetes, alcoholism and lead poisoning

Clinical presentation

• Pt presents with numbness, tingling, pain and burning of the anterolateral thigh
• Standing relieves symptoms and sitting exacerbates symptoms
• Ex:
  • shows decreased sensitivity to pain, touch and temp in the LFCN distribution. 
  • Palpating it may aggravate the Sx
  • There may be an area of skin loss in the distribution of the LFCN where the skin was massaged to relieve symptoms
  • If in doubt, injecting LA into area may eliminate symptoms
• Investigations
  • Nerve condition studies (if needed)
  • Plain pelvic X-ray: to rule out pelvic tumours and hip OA
• DDx:
  • Lumbar spine pathology, Hip OA, Diabetic amyotrophy 
• Management
  • Non operative Mx
    • Avoiding compression of the nerve, loosening belts and losing weight
    • NSAIDs
    • TCA and anticonvulsants may be required for Rx of neuralgia
    • Local injection of corticosteroids at the site of the nerves as they cross the inguinal ligament may help reduce the swelling around the nerve.
    • Topical capsaicin
    • Non-operative Mx beneficial in 50-75% of cases
  • Operative Mx
    • Consider if disabling Sxs persist at one year
    • Neurolysis, neurolysis with transposition of the nerve and transection
    • Neurolysis
      • surgical release of the nerve sheath and freeing up the nerve
      • preferred option initially
      • successful in 50% of pts
      • if symptoms recur after neurolysis, nerve should be sectioned which leaves an area of numbness in the nerve distribution but gets rid of the pain

Trochanteric bursitis 

• painful inflammation of the bursa located just superficial to the greater trochanter of the femur, between the greater trochanter and the gluteus medium/iliotibial tract
• Inflammation: may be due to acute or repeated trauma
  • Acute: contusions from falls, contact sports etc 
  • Repetitive trauma: bursal irritation due to friction from the iliotibial band, which is an extension of the tensor fascia lata muscle
• Pre-disposing factors:
  • leg length discrepancy, lateral hip surgery 
• Clinical features
  • Anyone can get it
  • Common in older pts
  • Mistaken for hip arthritis or lumbar spine pathology
  • Pts complain of lateral hip pain but hip joint itself is not involved
  • Pain may radiate down the lateral aspect of the thigh
  • Does not radiate beyond the knee
  • Onset of Sxs is variable: acute or insidious (usually related to increase in exercise activity)
  • Pain when laying on affected side with associated limping and sleep disturbances
  • Pt may report that pain limits their strength and makes their leg feel weak
• Classic finding:
  • point tenderness over the posterior third of the greater trochanter, which reproduces the pain (enough to make the diagnosis)
  • Can elicit lateral hip pain by passive external rotation of the hip in extension, while internal rotation will not provoke these symptoms. 
  • Lateral hip pain can also be reproduced with flexion of the hip followed by resisted hip abduction.

• Differential diagnosis
  • Groin, thigh or knee pain provoked by passive internal rotation of the hip may indicate hip joint pathology such as OA
  • Lumbosacral radiculopathy
  • # of femur
  • Insertional abductor tendonitis 
• Imaging
  • Plain Xray of pelvis, hip and femur: #, underlying degenerative arthritis, bony lesions, pelvic tilting due to leg length discrepency
  • Bone scan, CT, MRI
  • If there is suggestion that pain is due to mets, perform bone scan even if Xray is normal 
• Treatment
  • Relative rest: restriction of pain-causing activities and avoiding direct pressure on the affected bursa
  • Physiotherapy: teach pt home exercise program, emphasising stretching
  • US and soft tissue massage
  • TENS in resistant cases
  • NSAIDs
  • Address gait issues: cane, orthotics, walker, shoe, knee brace etc 
  • Corticosteroid injection into bursa (bursa lies over the posterior 3rd of the greater trochanter)
    • Complications after injection
      • Infection, Bleeding, Bruising, Allergic reaction, Elevated blood glucose levels for about 3 days in pts with diabetes
• Prognosis
  • Pts respond well to combo of: corticosteroid injection, physiotherapy, activity restriction
  • Some pts need a repeat corticosteroid injection

Snapping hip (coxa saltans) 

• Internal: due to iliopsoas tendon flicking over the femoral head, and the pt complaining of a reproducible, often audible, palpable low clunk in the groin, usually unilateral.
• External: iliotibial band snapping over the greater trochanter

Osteitis Pubis

1. Diagnosis Criteria:
   • No standard clinical criteria.
   • Common findings:
     • adductor/pubic groin pain during exercise
     • tenderness over pubic symphysis/bone, pain with weakness in provocation tests
       • squeeze test
       • bilateral hip adduction test
2. Investigation Approach:
   • Initial: Bone scan.
   • Follow-up: Limited fine slice CT scan of pubic symphysis if bone scan is positive.
   • CT scan preferred for showing degenerative changes in cortical bone.
3. MRI Utility:
   • Useful for showing pubic bone marrow edema, indicating trabecular bone stress injury.
   • Mixed reports on its clinical usefulness.
   • MRI finding of linear parasymphyseal T2 hyperintensity potentially more relevant than bone marrow edema.
4. Risk Factors:
   • Limited hip range of motion (especially internal rotation), weakness in hip adduction/abduction strength, training errors.
   • Sudden increase in training frequency/duration/intensity raises risk.
   • Preseason training protective.
   • High risk in individuals with skeletal immaturity under high training loads.
5. Rehabilitation Techniques:
   • Conservative exercise program: core stabilization, adductor, abductor, abdominal, lumbar extensor strengthening, balance exercises.
   • Inclusion of transversus abdominis and pelvic floor exercises.
   • Graduated return to sport to prevent recurrence.
6. Treatment Options:
   • Conservative treatment includes rest, muscle strengthening, core stabilization.
   • Comparable outcomes with prolotherapy injections, corticosteroid injections, and surgery in some cases.

Incipient Hernia

1. Terminology and Understanding:
   • Various names used: incipient direct inguinal hernia, posterior inguinal wall deficiency, symphysis syndrome, weak groin, athletic pubalgia, etc.
   • Suggests poor understanding of the condition.
2. Pelvic Compression Belt Usage:
   • Parallels with postpartum posterior pelvic pain.
   • Pelvic compression belt: helps in pain reduction, increases power in resisted adduction and active straight leg raise test.
   • Aids in rehabilitation by facilitating load transfer and reducing pain inhibition.
3. Rehabilitation Focus:
   • Aim to normalize transversus abdominis and anterior pelvic floor muscle function.
   • Restores compressive forces across pubic symphysis.
   • Goal: achieve internal stability without external belt compression post-rehabilitation.
4. Clinical Features:
   • Inguinal groin pain during exercise.
   • Positive squeeze test, active straight leg raise test.
   • Widening of superficial inguinal ring, tenderness superolateral to pubic tubercle, pain with positive cough impulse.
5. Similarities with Osteitis Pubis:
   • Common features with osteitis pubis: inguinal groin pain, pain on resisted adduction, tenderness over adductor origins.
   • Anterior pelvic floor reconstruction effective even in osteitis pubis cases.
   • Possible overlap between incipient hernia and osteitis pubis, potentially representing the same condition.

Sacroiliitis / Sacraliliac Joint Pain

• Pain at the sacroiliac joint is often in the posterior or buttocks region.
• often causing pain and is a diagnosis of exclusion.
• The SI joint, one of the largest in the body, connects the ilium to the sacrum, and is a common source of buttock and lower back pain.
• Its symptoms resemble other back pain sources, making diagnosis challenging.
• Causes include chronic degeneration and conditions like ankylosing spondylitis, psoriatic arthropathy, and infections.
• Etiology:
  • Osteoarthritis can lead to joint degeneration and sacroiliitis.
  • Spondyloarthropathies, pregnancy (due to the hormone relaxin), trauma, and infections are other causes.
  • Pain may originate from the synovial joint or posterior sacral ligaments.
• Epidemiology:
  • Prevalence varies, with 10% to 25% of lower back pain cases linked to sacroiliitis.
  • Pain typically presents in the ipsilateral buttock (94% of cases) and lower lumbar area (74%).
• Pathophysiology:
  • The SI joint distributes body weight to the pelvis.
  • Joint capsule defects, asymmetrical pelvis motion, and surrounding muscle issues can lead to pain.
  • Pain often follows L4-L5 dermatomes, but can range from L2 to S3.
• History and Physical:
  • Presents as lower back pain, varying in location and description (sharp, stabbing, dull, achy).
  • Worsens after sitting or with rotational movements.
  • Important to investigate history of inflammatory disorders and systemic symptoms (fevers, chills, night sweats, weight loss).
  • Physical examination may reveal
    • pelvic asymmetry
    • leg-length discrepancies,
    • spinal abnormalities.
  • Range of motion, neurologic, and strength tests typically unremarkable, but may induce pain.
  • Pain in the sacroiliac joint can be elicited with the FAbER Test.
    • FAbER stands for Flexion, Abduction and External Rotation.
    • Once the leg is flexed, abducted and externally rotated (as noted in image below), you will apply a downward pressure at the knee.
    • The presence of pain in the posterior (or buttocks) region suggests pain from the sacroiliac joint.

Link to video demonstrating this. 

Comparison of Pediatric Hip Conditions

Condition	Developmental Dysplasia of the Hip (DDH)	Legg-Calvé-Perthes Disease	Slipped Capital Femoral Epiphysis (SCFE)
Pathology	Abnormal development of the hip joint, improper seating of femoral head in acetabulum Risk Factors: Family history, breech presentation, female sex, first-born status.	Avascular necrosis of the femoral head Risk factors: positive family history low birth weight, abnormal birth presentation, second hand smoke Asian, Inuit, and Central European decent	Displacement of the femoral head relative to the femoral neck
Presentation	Asymmetry of thigh or gluteal folds limited hip abduction leg length discrepancy	Limping hip or knee pain limited range of motion	Hip, groin, thigh, or knee pain limping restricted range of motion
Symptoms	Newborns: Asymptomatic initially Older children: Pain, limping, waddling gait	Limp including painless limp Atraumatic intermittent ache in hip, thigh or knee  Insidious onset	Pain often gradual, limping, restricted hip motion
Age of Onset	Birth to early infancy	4-8 years (most common)	Adolescents (10-16 years)
Risk Factors	Family history, breech presentation, female sex, first-born status	Boys, ages 4-8, family history, low birth weight	Obesity, rapid growth spurts, endocrine disorders
Diagnosis	Physical exam (Ortolani and Barlow tests), ultrasound, X-rays	X-rays, MRI (early stages)	X-rays, MRI for early detection
Treatment	Pavlik harness, closed or open reduction, casting, surgery	Containment of femoral head (bracing, casting), surgery Limp including painless limp	Non-weight bearing, surgical pinning
Complications	Hip dysplasia, early osteoarthritis, gait abnormalities	long-term studies suggest that most patients do well until fifth or sixth decade of life joint deformity, early osteoarthritis, gait abnormalities	Osteonecrosis Chondrolysis Osteoarthritis femoral acetabular impingement Contralateral hip SCFE  residual proximal femoral deformity & limb length discrepancy