Differential diagnosis of pain around the hip joint

Nonpelvic comorbid symptoms of 45 patients with pain of pelvic venous origin, before and after treatment

OBJECTIVE

To report the prevalence and severity of nonpelvic symptoms for patients with venous-origin chronic pelvic pain (VO-CPP) and to describe outcomes after pelvic vein stenting and embolization.

METHODS

We retrospectively reviewed outcomes of 45 women with VO-CPP who underwent treatment with iliac vein stenting and/or embolization. Patients completed symptom-severity questionnaires before and after treatment that assessed for pelvic pain, and multiple other symptoms, including brain fog, anxiety, depression, musculoskeletal pain, fatigue, migraines and more.

RESULTS

Patient age ranged from 18 to 65 years. The prevalence of common symptoms was as follows: migraines, 69%; brain fog, 76%; anxiety attacks, 58%; excess sweating, 64%; hip pain, 73%; diarrhea, 62%; constipation, 76%; and abdominal bloating, 82%. After treatment, most symptom scores improved by more than 50%; exceptions were excessive sweating (41% improvement) and bloating (47% improvement). Prevalence of individual symptoms that bundle into POTS ranged from 29% to 76%, where symptom improvement ranged from 23% to 59% after treatment. Overlapping individual symptoms characteristic of fibromyalgia and myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) were present in 64% to 82% of patients and all improved by 49% to 63% after treatment.

CONCLUSIONS

Pelvic venous flow abnormality is linked causally to a spectrum of interrelated symptoms, of which many can be bundled into named syndromes of unknown cause. With catheter- based treatment of pelvic venous pooling, nonpelvic symptom and syndrome scores improved.

Effect of conservative treatment on greater trochanteric pain syndrome: a systematic review and network meta-analysis of randomized controlled trials

OBJECTIVE

Numerous studies have investigated conservative treatments for GTPS. However, there remains a lack of comparative analyses among treatment modalities, making it challenging to formulate the optimal conservative treatment strategy. This study aimed to compare conservative treatments for greater trochanteric pain syndrome (GTPS) in terms of their effectiveness in relieving pain and improving functional outcomes.

METHODS

In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, the PubMed, Embase, Cochrane Library and ClinicalTrials.gov along with other databases were searched to identify relevant studies. The quality of the selected studies was evaluated using risk of bias assessments, and the data were extracted. Network meta-analysis was performed using random effects models to evaluate the effects of treatment modalities on pain reduction and functional improvement. The evidence of the included studies was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluations framework.

RESULTS

Nineteen RCTs involving 1701 participants were included. The risk of bias was assessed using Cochrane ROB2. The results of network meta-analysis revealed that exercise therapy yielded the most significant improvement on reducing pain scores measured using the NRS and enhancing functional outcomes measured using the VISA-G. Additionally, injection therapy showed significant advantages in improving functional outcomes measured by using the Harris Hip Scale.

DISCUSSION

This study confirmed the significant efficacy of exercise programs on pain reduction and functional improvement in GTPS patients. Additionally, we identified the positive effects of injection therapy and physical modalities on managing pain and enhancing functional outcomes among GTPS patients. Owing to the limited number of included studies, comparing the effects of different conservative treatments remains challenging. Future studies should expand the quantity of RCTs to identify the optimal conservative treatment strategy for GTPS.

CONCLUSION

This study reaffirmed the superiority of exercise therapy in the treatment of GTPS and revealed the effectiveness of injection and physical modalities. As the number of studies increase, we anticipate more reliable conclusions to further optimize conservative treatment strategies for GTPS. Ultimately, our study can help clinicians determine the optimal conservative treatment for GTPS and may spur future research on conservative treatments for tendinopathy.

Air arthrography: a safe technique for intra-articular hip injections

INTRODUCTION

Diagnosing the specific causes of young adult hip pain remains challenging due to non-specific symptoms. Fluoroscopy-guided injections are useful for confirming intra-articular hip pain and differentiating it from extra-articular pathology. When performing injections, accurate needle placement into the hip joint is critical. Traditionally, a contrast agent is used to confirm intra-articular positioning. Air arthrograms are an alternative technique that avoids adverse reactions to contrast, which may compromise interpretation of results, as well as being more cost-effective. This study presents the air arthrography technique for intra-articular hip injections, and assesses outcomes and complications in a consecutive patient cohort.

METHODS

A retrospective review was performed on patients who underwent an air arthrography guided intra-articular hip injection at a single institution between April 2019 and September 2022. We identified 352 hips in 294 patients. Patient records were evaluated for complications from the injection or any subsequent hip surgery.

RESULTS

Mean age at time of injection was 38 years (±14.7 SD) for 216 females and 78 males. Mean follow-up time post injection was 138 days (IQR = 46-186). Results showed a 2.56% complication rate, primarily attributed to steroid flares, all of which resolved without further intervention. 102 patients proceeded to subsequent hip surgery; the mean time from injection to procedure was 341 days (IQR = 194-456) and the mean follow-up post subsequent procedure was 346 days (IQR = 87-531). There were no infective complications following the injections or any subsequent procedures.

CONCLUSIONS

This is the first study that evaluates longer-term patient outcomes following air arthrography guided injections with or without subsequent surgery. Our results demonstrate that the use of air arthrograms is a reliable, safe, and cost-effective method for intra-articular hip injections, without the additional risks posed by contrast media.

Assessment of the piriformis muscle and piriformis syndrome via Web of Science database: A bibliometric analysis

BACKGROUND

Piriformis syndrome, which is seen as the cause of 0.3% to 6% of low back pain, is a painful condition that occurs as a result of compression of the piriformis muscle on the sciatic nerve. Although there are many studies in the literature about piriformis syndrome, no bibliometric analysis has been found. This study aims to evaluate piriformis syndrome and conduct a bibliometric analysis of studies related to piriformis muscle and syndrome.

METHODS

This study was conducted on March 27, 2024, using data recorded in the Web of Science Core Collection Database. The search was made as "Topic = Piriformis OR Piriformis Syndrome." Accordingly, 1345 results were found, and as a result of the necessary inclusion and exclusion criteria, 961 documents remained. The data was transferred to the VOSviewer software for further analysis.

RESULTS

961 documents based on piriformis muscle or piriformis syndrome were obtained. The country with the most publications was reported to be the USA with 31.42%. Other countries are ranked at around 5% or less. While 9 of the top 10 most cited institutions are based in the USA, clinics that make significant research contributions also attract attention among these institutions. Journals that publish articles containing piriformis syndrome are prominently surgery, physical therapy, anatomy, and general medicine journals. The most repeated keywords were reported as piriformis syndrome, diagnosis, pain, muscle, sciatic nerve, and hip. In contrast, the most repeated clinical terms were reported as approach, surgery, piriformis muscle, injection, sciatica, and compression.

CONCLUSION

The findings obtained in this study are thought to be important for understanding to providing literature with new perspectives on this subject. They will also focus on the missing parts of the subject from this perspective. Also, this study would provide a novel perspective to the studies about piriformis syndrome and contribute to the researchers about the limits of the topic, and being aware of the active journals that publish papers on this issue would facilitate the work of the researchers.

Integrating manual therapy into conservative management of a patient with bilateral femoral head avascular necrosis: A case report with a 2-year follow up

BACKGROUND

Femoral head avascular necrosis (AVN) can contribute to substantial functional limitation. Although surgical intervention for advanced staged AVN can be useful, non-surgical interventions to improve functional independence of patients with hip AVN are not well described.

OBJECTIVE

The purpose of this case report is to describe the physical therapy intervention provided to a patient with bilateral hip AVN.

METHODS

The patient was a 56-year-old male presenting to physical therapy with bilateral femoral head AVN. Impairment-based manual therapy, therapeutic exercise, and education were provided to promote decreased pain and improved self-reported function.

RESULTS

The patient completed eight visits over the course of 10 weeks. Clinically significant improvements were noted in pain ratings and functional level as measured by the Lower Extremity Functional Scale and Harris Hip Score. Improvements were maintained at a two-year follow up period.

CONCLUSION

Early identification and physical therapy intervention can contribute to promoting functional independence for patients with bilateral hip AVN. Early intervention could potentially reduce the need for surgical intervention. Further research is necessary to describe with detail the optimal methods to accomplish these goals.

Insights into Hip pain using Hip X-ray: Epidemiological study of 8,898,044 Koreans

Hip pain is a prevalent degenerative joint symptoms, imposing a significant global health burden. Hip pain is experiencing an increase in incidences in Korea due to its aging society, and the social burden of hip pain continues to rise as the hip joint is crucial for gait and balance. This study assessed the epidemiology of hip pain in Korea using data from the fifth version of Korea National Health and Nutrition Examination Survey (KNHANES V-5). The research analyzed data from 8,898,044 Koreans to evaluate the prevalence and characteristics of hip pain and abnormal hip X-ray. Variables encompassed medical, demographic, mental, social, and musculoskeletal factors. Descriptive analysis and propensity score matching analyses unveiled characteristics of Koreans experiencing hip pain or showing abnormal hip x-ray. The study provides insights into the epidemiology of hip pain in the entire Korean population, and further suggesting the effective management of hip pain.

Case 326: Intra-Articular Osteoid Osteoma

HISTORY

A 15-year-old male patient presented with a 3-week history of inner left thigh pain provoked by activity and experienced occasionally at rest. The patient denied nighttime pain, fever, or chills. Laboratory investigation revealed the following normal values: hemoglobin level of 15.6 g/dL (normal range, 13-16 g/dL), platelet count of 240 × 103/µL (normal range, 140-440 × 103/µL), and total leukocyte count of 7100 cells/µL (normal range, 4500-11 000 cells/µL). The percentage of neutrophils was considered low at 44% (normal range, 54%-62%), and the percentage of eosinophils was slightly high at 3.7% (normal range, 0%-3%). An anteroposterior radiograph of the left hip is shown. Physical therapy was initiated, with no improvement after 2 weeks of therapy. The patient was referred to an orthopedist for further evaluation. At physical examination, the patient endorsed marked left hip pain with hip flexion to 90°, limited internal and external rotation (5° and 15°, respectively), and antalgic gait favoring the left leg. Hip MRI and further serologic analysis were requested for further evaluation. Although the serologic testing was performed at an outside laboratory, the physician reported positive immunoglobulin-G Lyme titers, normal C-reactive protein level, and normal erythrocyte sedimentation rate. Pelvic CT was requested. The patient was prescribed a course of doxycycline (100 mg twice daily for 28 days), with reported resolution of symptoms 2 weeks after initiation of treatment. Three weeks later, the patient presented to our department with recurrent left hip pain, which was similar in severity compared with the initial presentation. A second MRI examination of the left hip was performed 4 months after the initial presentation.

Iliotibial Band Origin Tendinopathy Is an Underrecognized Cause of Anterolateral Hip Pain: A Narrative Review and Clinical Commentary

ABSTRACT

Hip pain is a common concern among athletes. With gluteal tendinopathy, femoroacetabular impingement, and osteoarthritis predominating sports medicine and musculoskeletal practices, less common etiologies may be overlooked. Complex pelvic anatomy and variable pain referral patterns may make identifying an accurate diagnosis challenging. Employing a systematic approach to evaluation and having a thorough understanding of hip region anatomy are essential. A potentially overlooked cause of anterolateral hip pain is iliotibial band origin tendinopathy. Patients often present with pain around the anterolateral hip and tenderness to palpation at the anterolateral iliac crest. While patients with iliotibial band origin tendinopathy usually respond to nonsurgical intervention, there is little literature to guide evaluation and treatment, highlighting a gap in the recognition of this condition. The purpose of this narrative review is to describe the anatomy of the proximal iliotibial band origin, outline the clinical diagnosis and imaging findings of ITBOT, and summarize current treatment options.

Unusual Presentation of Hip Pain in a Pregnant Woman Due to Bilateral Cervical Neck Stress Fractures: A Case Report

CASE

We present an unusual case of bilateral femoral neck fatigue fractures in a 28-year-old pregnant woman at the 18th week of gestation successfully treated through operative intervention involving consecutive total hip arthroplasty and internal fixation within the same procedure, resulting in favorable clinical outcomes.

CONCLUSION

Current clinical practices suggest that a restricted use of plain radiographs, even those involving the pelvis in pregnant women carries a minimal risk to the fetus and is not contraindicated. Magnetic resonance imaging proved valuable for differential diagnosis, contrasting with sonography.

No difference in prevalence of postoperative iliopsoas tendinitis in patients undergoing arthroscopic hip surgery when using absorbable versus non-absorbable suture for capsular closure

PURPOSE

The volume of arthroscopic hip surgery has increased dramatically in recent years with iliopsoas tendinitis (IPT) being one of the most common complications of this procedure. The purpose of this study is to investigate the prevalence of post-operative IPT in patients who undergo arthroscopic hip surgery with capsular closure using absorbable versus non-absorbable suture.

METHODS

This is a single center, single surgeon, retrospective analysis performed between August 2007 and May 2023 comparing two cohorts who underwent hip arthroscopy. Patients were divided into those who underwent surgery with capsular closure using absorbable (Vicryl®, Johnson and Johnson, New Brunswick, NJ) suture and those who underwent capsular closure with non-absorbable suture (Suturetape, Arthrex, Naples FL). All patients who underwent primary or revision hip arthroscopy and were at least 2 months post-operation were initially included in the study.

RESULTS

Between August 2007 and May 2023 a total of 1513 hip arthroscopy surgeries were performed. Within this cohort, 1421 hips underwent hip arthroscopy with non-absorbable suture and 64 hips underwent surgery with absorbable suture. There was no significant difference between the proportion of IPT in the non-absorbable cohort (2.3%) versus the absorbable cohort (1.6%) (P = 0.669).

CONCLUSION

Capsular closure with Absorbable sutures was non-inferior to capsular closure with non-absorbable sutures with respect to the proportion of post-operative IPT following hip arthroscopy for FAI. Additionally, the proportion of post-operative IPT was found to be significantly higher in patients undergoing revision versus primary hip arthroscopy, regardless of capsular closure suture type.

LEVEL OF EVIDENCE

IV.

Femoroacetabular impingement - What the rheumatologist needs to know

Femoroacetabular impingement (FAI) syndrome is a common cause of hip and groin pain in young individuals. FAI syndrome is a triad of signs, symptoms, and imaging findings. Necessary but not sufficient for the diagnosis of FAI syndrome is the presence of cam and/or pincer morphology of the hip. However, pathological thresholds for cam and pincer morphologies are not well-established. Management of FAI syndrome is typically through either physiotherapist-led therapy or surgical intervention. Physiotherapist-led management involves exercises aimed to optimise movement patterns of the hip and pelvis to prevent impingement from occurring, activity modification and analgesia, whereas surgical management involves arthroscopic resection of the cam/pincer morphology and treatment of concomitant soft tissue pathologies such as labral tears, cartilage lesions or ligamentum teres tears. Careful consideration of intervention is required given that FAI syndrome may predispose those affected to developing future osteoarthritis of the hip. In most clinical trials, hip arthroscopy has been found to provide greater improvement in patient-reported outcomes in the short-term compared to physiotherapy, however it is unknown whether this is sustained in the long-term or affects the future development of hip osteoarthritis.

Management of Greater Trochanteric Pain Syndrome After Total Hip Arthroplasty: Practice Patterns and Surgeon Attitudes

INTRODUCTION

Greater trochanteric pain syndrome (GTPS) or trochanteric bursitis is described as pain on the lateral side of the hip that does not involve the hip joint and can be elicited clinically by palpation over the greater trochanter. To date, there remains no consensus on clinical guidelines for either diagnosis or management of GTPS.

METHODS

To understand the practice patterns, beliefs, and attitudes relating to the management of GTPS after total hip arthroplasty, a survey was developed and completed by Canadian arthroplasty surgeons. The final survey consisted of 23 questions divided into three sections: 1) screening questions; 2) demographic information; and 3) practice patterns, attitudes, and beliefs.

RESULTS

Most surgeons use physical examination alone for diagnosis. A detailed analysis indicates that surgeons primarily treat GTPS with oral anti-inflammatories (57.1%), structured physiotherapy (52.4%), and steroid injections (45.2%). Management options are typically nonsurgical and comprise a combination of either unstructured or targeted physiotherapy, corticosteroid injections, or platelet-rich plasma.

DISCUSSION

There remains an absence of clinical consensus for the diagnosis and management of GTPS after total hip arthroplasty. Physical examination is most often relied on, regardless of the availability of imaging aids. While common treatments of GTPS were identified, up to one-third of patients fail initial therapy.

Team Approach: Hip Preservation Surgery

The evaluation and treatment of adolescents and young adults with hip pain has seen tremendous growth over the past 20 years. Labral tears are well established as a common cause of hip pain but often occur because of underlying bony abnormalities. Femoroacetabular impingement (FAI) and acetabular dysplasia are now well-established causes of hip osteoarthritis and are increasingly treated in the prearthritic stage in hopes of improving symptoms and prolonging the longevity of the native hip. Beyond FAI and acetabular dysplasia, this patient population can present with a complex and variable group of underlying conditions that need to be taken into account. Expertise in the conservative management of this population, including physical therapy, is valuable to maximize the success. Preoperative, surgical, and postoperative decision-making and care in this population is complex and evolving. A comprehensive, multidisciplinary approach to the care of this patient population has been used for over 20 years by our institution with great success. The purpose of this article is to review the "team-based approach" necessary for successful management of the spectrum of adolescent and young adult hip disorders.

Snapping Hip Syndrome: Pathoanatomy, Diagnosis, Nonoperative Therapy, and Current Concepts in Operative Management

» Asymptomatic snapping hip affects 5% to 10% of the population; when pain becomes the primary symptom, it is classified as snapping hip syndrome (SHS).» The snap can be felt on the lateral side of the hip (external snapping hip), often attributed to an iliotibial band interaction with the greater trochanter, or on the medial side (internal snapping hip), often attributed to the iliopsoas tendon snapping on the lesser trochanter.» History and physical examination maneuvers can help distinguish the etiology, and imaging may help confirm diagnosis and rule out other pathologies.» A nonoperative strategy is used initially; in the event of failure, several surgical procedures are discussed in this review along with their pertinent analyses and key points.» Both open and arthroscopic procedures are based on the lengthening of the snapping structures. While open and endoscopic procedures both treat external SHS, endoscopic procedures typically have lower complication rates and better outcomes when treating internal SHS. This distinction does not appear to be as noticeable in the external SHS.

Femoral Neck Stress Fracture of a Male, Healthy Marathon Runner - Case Report and Literature Review

In the present report, a case of a healthy, 38-year-old male recreational marathon runner who presented in the emergency department is discussed. He was diagnosed with a stress fracture of the femoral neck and treated surgically using a dynamic hip screw (DHS). One year after surgery, the patient was able to return to most of his previous sports activities. In the present report, the existing literature on the subject is exhibited and the points of interest in terms of incidence, risk factors, diagnosis, classification, treatment, and long-term outcome are analyzed. We suggest operative treatment of stress fractures of the femoral neck even in cases of complete undisplaced ones. This way, the risk of a displacement is counteracted, and patients can quickly return to daily activities without having to withstand long-term immobilization.

Endoscopic Gluteus Medius Repair

Endoscopic gluteus medius repair is indicated after failed conservative management for debilitating peritrochanteric hip pain. In our experience, most of these surgeries are performed on women, 45 to 75 years old. Often for undersurface high-grade partial-thickness tears and some small full-thickness tears, a single-row repair technique is performed. For larger, full-thickness tears, a double-row repair is often performed. For minimal, superficial, partial-thickness tears with a longitudinal component of tearing through the gluteus medius tendon, a side-to-side repair is performed. Short-term follow-up shows significant improvements in hip outcome score for activities of daily living and in numeric rating scale.

Effect of Sacroiliac Joint Pain on Outcomes in Patients Undergoing Hip Arthroscopy for the Treatment of Femoroacetabular Impingement Syndrome: A Matched Comparative Cohort Analysis at Minimum 2-Year Follow-up

BACKGROUND

Patients with femoroacetabular impingement syndrome (FAIS) may frequently have co-existing sacroiliac joint (SIJ) pain. It is known that patients with lower back pain undergoing total hip arthroplasty (THA) have inferior outcomes; however, it is unclear what the effect of SIJ pain is on outcomes after hip arthroscopy.

PURPOSE

To determine whether patients undergoing hip arthroscopy with SIJ pain either subjectively or on physical examination achieve similar postoperative improvement in patient-reported outcomes (PROs) compared with patients without SIJ pain at 2-year follow-up.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Patients with a minimum 2-year follow-up who underwent primary hip arthroscopy for FAIS with SIJ pain were matched in a 1:2 ratio to controls without SIJ pain. Baseline demographics, as well as postoperative PROs and rates of achievement of the minimal clinically important difference (MCID) or Patient Acceptable Symptom State (PASS) at 2-year follow-up were compared between the 2 groups.

RESULTS

A total of 73 patients (75 hips) with SIJ pain were matched to 150 control patients (150 hips) without SIJ pain. Both groups demonstrated statistically significant improvement in all PROs at 2 years (P < .05 for all). Patients with SIJ pain had significantly lower postoperative PRO scores for the Hip Outcome Score-Activities of Daily Living (HOS-ADL) (SIJ pain: 80.4 ± 22.4 vs no SIJ pain: 88.0 ± 15.1; P = .006), modified Harris Hip Score (mHHS) (SIJ pain: 73.2 ± 22.8 vs no SIJ pain: 80.0 ± 17.3; P < .001), and International Hip Outcome Tool-12 questionnaire (iHOT-12) (SIJ pain: 61.7 ± 25.9 vs no SIJ pain: 73.7 ± 23.7; P = .008). There were no statistically significant differences in improvement (delta) in PRO scores between the 2 groups (P > .05 for all). The SIJ pain group had significantly lower achievement of MCID for the HOS-ADL (SIJ pain: 65.2% vs no SIJ pain: 80.5%; P = .044) but not HOS-SS, mHHS, or iHOT-12 (P > .05 for all). The SIJ pain group had significantly lower achievement of PASS for the mHHS (SIJ pain: 27.5% vs no SIJ pain: 45.3%; P = .030) and iHOT-12 (SIJ pain: 31.0% vs no SIJ pain: 56.0%; P = .010) but not the HOS-ADL and HOS-SS (P > .05 for both). Only 4.1% of patients with SIJ pain and 2.4% of controls required revision surgery or converted to THA at the time of final follow-up (P = .69).

CONCLUSION

Patients with FAIS and SIJ pain on history or physical examination experience significant improvement in PROs at 2 years after hip arthroscopy. However, they may be less likely to achieve the MCID or PASS and have significantly lower postoperative PROs compared with a matched cohort of patients without SIJ pain. Overall rates of revision and conversion to THA were similarly low in both groups.

Two-Tiered Resection of Cam Lesions in Hip Femoroacetabular Impingement: Optimizing Femoral Head Sphericity

Hip arthroscopy is one of the most rapidly growing fields in orthopaedic surgery. One of the most frequent pathologies treated with hip arthroscopy remains femoroacetabular impingement, which is addressed by labral repair and femoral osteoplasty. The most commonly cited reason for failure of arthroscopic treatment of femoroacetabular impingement is under-resection of the cam lesion. Surgeons frequently use evaluations of preoperative images, intraoperative fluoroscopy, and dynamic range of motion to ensure adequate resection. In this article, we describe a reproducible and standardized technique to assist in appropriate resection. This is achieved by a 2-tiered resection technique: Tier 1 aims to set the depth of resection and restore the head-neck offset. Tier 2 then matches the depth of the resection set by tier 1 and allows for retention of appropriate transition of the proximal convexity to the distal concavity seen in more ideally shaped femoral heads. With this technique, we offer a tool to avoid under-resection in the area of maximal conflict while simultaneously minimizing the risk of proximal over-resection and thus compromising the fluid seal dynamics of the joint in deeper flexion angles.

Hip Gluteus Medius Tears Are Associated With Lower Femoral Neck-Shaft Angles and Higher Acetabular Center-Edge Angles

PURPOSE

1) To assess the possible relationship between the morphology of femur or acetabulum and the gluteus medius pathology. 2) To analyze the outcome of isolated arthroscopic treatment of femoroacetabular impingement (FAI) for patients with radiographic gluteus medius tear.

METHODS

We performed a retrospective study of FAI patients who underwent arthroscopy between January 2016 to December 2019. Demographic data, such as sex, age, body mass index (BMI), symptom duration, were collected. Radiographic parameters, including alpha angle, lateral center-edge angle (LCEa), femur neck-shaft angle (NSa), gluteus medius pathology, were also collected. Exclusion criteria were previous hip conditions, such as osteoarthritis (Tönnis grade > 1), rheumatoid arthritis, ankylosing spondylitis, snapping hip, previous surgery on the ipsilateral hip, or incomplete data. We followed up these patients with radiographic gluteus medius tear. No surgical procedure for gluteus medius was performed. The minimum follow-up period was 13 months. Patient-reported outcomes, such as modified Harris Hip score (mHHS), visual analog scale (VAS), and patient acceptable symptom state (PASS), as well as physical examination data, including tenderness at the greater trochanter, abductor weakness, limping gait, and positive Trendelenburg sign or test, were gathered preoperatively and postoperatively.

RESULTS

A total of 569 hips (314, 55.2% male) were collected eventually, with a mean age of 36.5 ± 10.4 years (range: 13.0 to ∼65.0). Gluteus medius pathology was found in 209 (36.7%) hips, including 41 (7.2%) partial-thickness tears and 10 (1.8%) complete tears. The NSa of the normal, tendinosis, partial tear, and complete tear groups was 133.8 ± 4.7°, 130.6 ± 3.8°, 129.4 ± 3.9°, and 129.6 ± 3.4°, respectively (P < .001). The LCEa of each group was 31.7 ± 35.7°, 33.3 ± 6.5°, 34.9 ± 6.8°, and 33.7 ± 8.1°, respectively (P = .004). On multivariable logistic regression analysis, lower NSa and higher LCEa were identified as risk factors for developing gluteus medius pathology (P < .001). For patients with gluteus medius tear, two cases were lost to follow-up and two cases had incomplete data. The mean follow-up period of the remaining 47 hips was 29.5 ± 12.9 (range: 13 to 59) months. The mHHS improved from 54.8 ± 19.1 to 90.1 ± 6.7 points (P < .001), and VAS decreased from 6.8 ± 1.6 to 3.0 ± 1.6 points (P < .001). Forty-two cases met the threshold of PASS, with a rate of 89%. The abductor strength increased from 4.1 ± 1.00 to 4.6 ± .7 grades (P = .002). However, for patients with a completely torn gluteus medius, improvement of abductor strength was not significant statistically (3.4 ± .9 to 3.9 ± .9, P = .234).

CONCLUSION

There was a correlation between lower NSa/higher LCEa and gluteus medius pathology. Isolated arthroscopic treatment of FAI for patients with radiographic gluteus medius tear can gain satisfactory patient-reported outcomes.

LEVEL OF EVIDENCE

Therapeutic case series, IV.

Surgical Technique of the "Up-The-Neck" View During Hip Arthroscopy for Femoroacetabular Impingement

In the setting of femoroacetabular impingement, arthroscopy versus open surgery confers many advantages. However, inadequate bony resection remains a concern and is the leading cause of revision surgery. Several strategies have been described to ensure a more-complete resection during hip arthroscopy. In this current technique article, the authors describe a modified anterior portal site view called the "up-the-neck" view. This view allows for greater visualization of the femoral head-neck junction and alleviates challenges faced when assessing resection intraoperatively. The "up-the-neck" view is achieved by placing a 70° arthroscope in the anterior lateral portal and subsequently rotating the camera 90°. The head-neck junction will appear horizontally, rather than vertically, on this view, which allows for the easy identification of missed imperfections. This may reduce the need for revision surgery and future investigation is necessary to determine the reoperation rates following this technique.

Hip Arthroscopy for Femoroacetabular Impingement-Associated Labral Tears: Current Status and Future Prospects

Femoroacetabular impingement (FAI) has emerged as a common cause of hip pain, especially in young patients. While the exact cause of FAI is unknown, it is thought to result from repetitive microtrauma to the proximal femoral epiphysis leading to abnormal biomechanics. Patients typically present with groin pain that is exacerbated by hip flexion and internal rotation. Diagnosis of FAI is made through careful consideration of patient presentation as well as physical exam and diagnostic imaging. Use of radiographs can help diagnose both cam and pincer lesions, while the use of MRI can diagnose labral tears and cartilage damage associated with FAI. Both non-operative and surgical options have their role in the treatment of FAI and its associated labral tears; however, hip arthroscopy has had successful outcomes when compared with physical therapy alone. Unfortunately, chondral lesions associated with FAI have had poorer outcomes with a higher conversion rate to arthroplasty. Capsular closure following hip arthroscopy has shown superior clinical outcomes and therefore should be performed if possible. More recently, primary labral reconstruction has emerged in the literature as a good option for irreparable labral tears. While non-operative management may have its role in treating patients with FAI, hip arthroscopy has developed a successful track record in being able to treat cam and pincer lesions, chondral damage, and labral injuries.

The Intergluteal Fat Stripe in Patients With Hip Abductor Tears

Background:

With a hip abductor tendon tear, widening of the intergluteal space, or “fat stripe,” is a characteristic change seen in and around the gluteus medius and minimus.

Purpose:

To determine the relationship of the intergluteal fat stripe in hips with pathologic abductor tears compared with the contralateral side and to evaluate the association of fat stripe size with hip-specific patient-reported outcome measures.

Study Design:

Case series; Level of evidence, 4.

Methods:

Of the 43 patients (42 female, 1 male; mean age, 56.6 years; range, 38-85 years) who underwent endoscopic gluteus medius repair, 19 met inclusion criteria of preoperative bilateral hip magnetic resonance imaging (MRI) scans and 2-year follow up. A single board-certified fellowship-trained orthopaedic surgeon (J.F.), who was blinded to outcomes, evaluated the MRI scans to measure the intergluteal fat stripe on the operative and nonoperative sides. The 2-year postoperative International Hip Outcome Tool (iHOT-12) and modified Harris Hip Score (mHHS) values were analyzed to determine their relationship to the size of the fat stripe. Statistical analysis was performed using a paired t test, and associations were determined using Pearson product correlation as well as nonparametric measurements.

Results:

The size of the intergluteal fat stripe differed significantly between the operative and nonoperative sides. The area of the fat stripe on the operative side was 645.73 ± 513.09 mm2, and on the nonoperative side it was 313.47 ± 360.71 mm2, an average of 332.36 mm2 greater than the nonoperative side ( P = .02). The width of the fat stripe was 9.10 ± 4.60 mm on the operative side and 5.15 ± 3.87 mm on the nonoperative side, 3.95 mm greater than the nonoperative side ( P < .01). There was no correlation between the width or area of the fat stripe on the operative side and iHOT-12 or mHHS values at 2-year follow-up.

Conclusion:

The study findings indicated that the intergluteal fat stripe is significantly wider and has a significantly larger area in hips with abductor tears compared with unaffected hips. This did not correlate with 2-year patient-reported outcomes.

Radiofrequency Ablation of the Trochanteric Branches of the Femoral Nerve for the Treatment of Greater Trochanteric Syndrome

Background

Approximately 10–15% of the population over the age of 60 suffers from hip pain. Greater trochanteric pain syndrome (GTPS) is one of the most common diagnoses in patients with chronic hip pain, includes a number of disorders, and has a broad differential diagnosis. Conservative managements of GTPS, including pharmacologic interventions, physical therapy, chiropractic intervention, acupuncture, and more invasive techniques, such as intra-articular injections, commonly fail to provide patients with sufficient, long-term relief. While radiofrequency ablation (RFA) has been used to treat intra-articular hip pain in the past, there is little evidence for the feasibility of RFA for managing patients with GTPS. This case series builds on previous evidence that cooled radiofrequency ablation (CRF) of the trochanteric branch of the femoral nerve may offer patients with GTPS effective, safe, and lasting pain improvement.

Cases

A series of eight patients with GTPS underwent CRF of the nervus females to the trochanter. CRF procedures were either targeted at the left, right, or bilateral nerves.

Conclusion

This case series provides additional evidence for the safety and effectiveness of CRF of the nervus femoralis to the trochanter for offering long-term pain relief in patients with GTPS. All patients experienced at least two months of relief, with most patients experiencing ongoing relief from the procedure.

Hip pain in an elite cyclist with Non-Hodgkin's Follicular Lymphoma: a case report

OBJECTIVE

We present a case of an elite cyclist that hesitated to follow the medical advice from her practitioners, as she was determined to train and compete resulting in delayed diagnosis and management of a rare hip pathology.

CASE PRESENTATION

A 51-year old elite female cyclist had a history of years of hip pain with insidious onset. The chiropractor in this case observed a lack of response to treatment, and advised the patient to get an MRI with suspicion of a labral tear. She eventually agreed to further investigations and was diagnosed with Non-Hodgkin's follicular lymphoma and a labral tear.

SUMMARY

Elite athletes are not immune to serious pathology. Chiropractors should be vigilant and ensure to investigate any patients with a lack of response to conservative management. Chiropractors should be aware of the risk of athletic patients that continue to train and compete when advised not to.

Snapping Hip Syndrome: A Comprehensive Update

Purpose of review

This is a comprehensive literature review regarding the pathogenesis, diagnosis, and treatment of snapping hip syndrome (SHS). It covers the diverse etiology of the syndrome and management steps from conservative to more advanced surgical techniques.

Recent Findings

Recent advances in imaging modalities may help in diagnosing and treating SHS. Additionally, arthroscopic procedures can prove beneficial in treating recalcitrant cases of SHS and have recently gained popularity due to their non-invasive nature.

Summary

SHS presents as an audible snap due to anatomical structures in the medial thigh compartment and hip. While often asymptomatic, in some instances, the snap is associated with pain. Its etiology can be broadly classified between external SHS and internal SHS, which involve different structures but share similar management strategies. The etiology can be differentiated by imaging and physical exam maneuvers. Treatment is recommended for symptomatic SHS and begins conservatively with physical therapy, rest, and anti-inflammatory medications. Most cases resolve after 6-12 months of conservative management. However, arthroscopic procedures or open surgical management may be indicated for those with persistent pain and symptoms. Different surgical approaches are recommended when treating internal SHS vs. external SHS. Due to advancements in treatment options, symptomatic SHS commonly becomes asymptomatic following intervention.

Successful Diagnosis of Sacroiliac Joint Dysfunction

Background

Sacroiliac joint (SIJ) pain is one of the most common causes of low back pain, accounting for 15 to 30% of all cases. Although SIJ dysfunction accounts for a large portion of chronic low back pain prevalence, it is often overlooked or under diagnosed and subsequently under treated. The purpose of this review was to establish a best practices model to effectively diagnose SIJ pain through detailed history, physical exam, review of imaging, and diagnostic block.

Methods

A literature search was performed on the diagnosis of sacroiliac joint pain and sacroiliac joint dysfunction. The authors proposed diagnostic recommendations based upon the available literature and a detailed understanding of diagnosing SIJ pain.

Results

The practitioner must focus on the history, location of pain, observed gait pattern, and perform key points of the physical exam including sacroiliac provocative maneuvers. If the patient exhibits at least three provocative maneuvers then the SIJ may be considered as a possible source of pain. Additionally, a thorough review of the imaging should be performed to rule out other etiologies of low back pain. In the absence of any pathognomonic tests or examination findings, diagnostic SIJ blocks have evolved as the diagnostic standard.

Conclusion

The diagnosis of SIJ pain is a multifaceted process that involves a careful assessment including differentiating other pain generators in the region. This involves careful history taking, appropriate physical examination including provocative maneuvers and diagnostic injections. Once the diagnosis is confirmed, long-term solutions may be considered, including recent advances in sacral lateral branch denervation and sacroiliac joint fusion.

A Current Update on Pelvifemoral Conditions That Should be in the Differential Diagnosis for Patients With Lower Extremity Radiculopathy

Patients presenting to an outpatient spine clinic frequently report symptoms of low back pain with associated buttock, groin, and lower extremity pain. While many of these individuals suffer from lumbar spine radiculopathy, a number of different orthopedic pathologies can mimic these symptoms. Management depends substantially on a detailed history and physical examination, in addition to working from a broad list of differential diagnoses when evaluating these patients. It is imperative that spine practitioners have a comprehensive understanding of the differential diagnoses that may mimic those originating from the lumbar spine, especially when a patient's symptoms are atypical from classic radicular pain. Misdiagnosis can lead to unnecessary testing and treatment, while delaying an accurate clinical assessment and treatment plan. This review highlights common orthopedic diagnoses that may present similar to lumbar spine pathologies and the evidence-based evaluation of these conditions.

Utilisation of exercise as part of guideline-based care for hip pain in the Australian workers' compensation environment

BACKGROUND

Guidelines recommend early referral for exercise for hip pain. It is unclear if this occurs in the Australian workers' compensation environment.

OBJECTIVE

To investigate referral for exercise in workers with a compensable hip claim.

METHODS

Retrospective audit of closed compensation files for workers with hip pain was performed. Exercise commencement was indicated by billing codes for physiotherapy or exercise specific consultations. Time to exercise commencement was calculated. Associations were analysed between time to exercise commencement with claim duration and diagnostic category.

RESULTS

Exercise management occurred for 33/44 cases. Median time to commence exercise for those cases that had exercise was 14 days post-injury, with 33% commencing beyond 4 weeks. Longer time to commence exercise was associated with a longer claim duration (Spearman's rho = 0.70). Workers with a diagnosis of hip joint pain had a longer time to exercise commencement (median 49.5 days) compared to those with a diagnosis of lateral hip pain (median 14 days) or non-specific hip pain (median 4.5 days).

CONCLUSION

Findings indicate practice behaviours in the workers' compensation environment for the management of hip pain with exercise. Further investigation is warranted to see if improved adherence to guideline recommendations improves outcomes for people with compensable hip pain.

Greater trochanteric pain syndrome: Evaluation and management of a wide spectrum of pathology

Greater trochanteric pain syndrome is a common cause of lateral hip pain, encompassing a spectrum of disorders, including trochanteric bursitis, abductor tendon pathology, and external coxa saltans. Greater trochanteric pain syndrome is primarily a clinical diagnosis, and careful clinical examination is essential for accurate diagnosis and treatment. A thorough history and physical exam may be used to help differentiate greater trochanteric pain syndrome from other common causes of hip pain, including osteoarthritis, femoroacetabular impingement, and lumbar stenosis. Although not required for diagnosis, plain radiographs and magnetic resonance imaging may be useful to exclude alternative pathologies or guide treatment of greater trochanteric pain syndrome. The majority of patients with greater trochanteric pain syndrome respond well to conservative management, including physical therapy, non-steroidal anti-inflammatory drugs, and corticosteroid injections. Operative management is typically indicated in patients with chronic symptoms refractory to conservative therapy. A wide range of surgical options, both open and endoscopic, are available and should be guided by the specific etiology of pain. The purpose of this review is to highlight pertinent clinical and radiographic features used in the diagnosis and management of greater trochanteric pain syndrome. In addition, treatment indications, techniques, and outcomes are described.

Isometric hip strength impairments in patients with hip dysplasia are improved but not normalized 1 year after periacetabular osteotomy: a cohort study of 82 patients

Background and purpose - In patients with hip dysplasia, knowledge of hip muscle strength after periacetabular osteotomy is lacking. We investigated isometric hip muscle strength in patients with hip dysplasia, before and 1 year after periacetabular osteotomy, and compared this with healthy volunteers. Furthermore, we investigated whether pre- to post-surgical changes in self-reported pain and sporting function were associated with changes in isometric hip muscle strength.Patients and methods - Isometric hip muscle strength was assessed twice in 82 patients (11 men) with a mean age of 30 (SD 9) years, before and 1 year after surgery, and once in 50 healthy volunteers. Isometric hip muscle strength was assessed with a hand-held dynamometer. Copenhagen Hip and Groin Outcome Score was used to measure self-reported outcome.Results - Despite 1-year improvements in isometric hip flexion (0.1 Nm/kg; 95% CI 0.06-0.2) and abduction (0.1 Nm/kg; CI 0.02-0.2), the patients' muscle strength was 13-34% lower than the strength of the healthy volunteers both pre- and post-surgery (p < 0.01). Moreover, changes in self-reported pain were associated with changes in hip flexion (13 points per Nm/kg; CI 1-26) and abduction (14 points per Nm/kg; CI 3-25), while changes in self-reported sporting function were associated with changes in hip extension (9 points per Nm/kg; CI 1-18).Interpretation - Isometric hip muscle strength is impaired in symptomatic dysplastic hips measured before periacetabular osteotomy. 1 year after surgery, isometric hip flexion and abduction strength had improved but muscle strength did not reach that of healthy volunteers.

Femoroacetabular Impingement and Core Muscle Injury in Athletes: Diagnosis and Algorithms for Success

Athletic hip injuries account for a substantial portion of missed time from sports in high-level athletes. For both femoroacetabular impingement (FAI) and core muscles injuries, a thorough history and physical examination are paramount to guide the treatment. While advanced imaging including computed tomography and magnetic resonance imaging are frequently obtained, a wealth of information can be ascertained from standard radiographs alone. For patients with isolated or combined FAI and core muscle injuries (CMIs), the initial treatment is often nonoperative and consists of rest, activity modification, and physical therapy of the hips, core, and trunk. Injections may then aid in both confirming diagnosis and temporary symptom abatement. Arthroscopic procedures for refractory FAI in experienced hands have been shown to be both safe and efficacious. While surgical repair options for CMIs are significantly more variable, long-term studies have demonstrated the rapid resolution of symptoms and high return to play rates. More recently, anatomic and clinical correlations between FAI and CMIs have been identified. Special attention must be paid to elite athletes as the incidence of concurrent FAI with CMI is extremely high yet with significant symptom variability. Predictable return to play in athletes with coexisting symptomatic intra-articular and extra-articular symptomatology is incumbent upon the treatment of both pathologies.

Ultrasound-guided hydrodilatation for adhesive capsulitis of the hip is a safe and effective treatment

Purpose

Adhesive capsulitis of the hip (ACH) is likely that this condition had been previously encountered, but easily unrecognised. We investigated the clinical features of patients with ACH, the efficacy of ultrasound-guided intra-articular hydrodilatation, and the patients’ prognosis.

Methods

We enrolled 84 patients (93 hips) who visited the outpatient clinic from August 2018 to November 2019. ACH was diagnosed by restricted range of motion and sharp pain when turning with the affected leg fixed on the ground. We evaluated patient demographics and associated intra-articular pathologies found on magnetic resonance angiography (MRA) images. Injections were performed twice at two week intervals with a mixture of 0.5% lidocaine (25 mL) and triamcinolone (40 mg; 1 mL) with capsular distension under ultrasound guidance. Patients were assessed before and after treatment using a visual analogue scale (VAS), hip disability and osteoarthritis outcome score (HOOS), hip range of motion (ROM), and distance from floor to knee (DFK) when sitting in the cross-legged position.

Results

On MRA, 18 patients had abnormal findings (eight labral tears, seven abductor tendinosis, three primary arthrosis). The mean VAS decreased from 7.1 ± 1.1 to 0.8 ± 0.9 after the last injection, and the HOOS improved in all subsets. The mean DFK decreased from 17.9 ± 4.8 to 9.7 ± 2.8 cm, and passive ROM showed improvement, especially in flexion and rotation. In seven patients, symptom recurrence was reported a mean of 4.1 months after the latest injection, but no independent risk factor for recurrence was identified.

Conclusion

Based on these current observations, patients with ACH may receive relief from hip joint pain and experience improved function with a timely diagnosis and effective treatment.

Assessment of the duration and effectiveness of intra-articular lidocaine injections for groin pain in patients with labral tears involving early osteoarthritis

Introduction: Intra-articular lidocaine injections have been used to confirm the hip pathology and may predict the efficacy of arthroscopic surgery. We have routinely performed the injections as a surgical indicator. The aim of this study was to assess the duration and effectiveness of these diagnostic intra-articular lidocaine injections on groin pain in patients with labral tears involving early osteoarthritis. Methods: A total of 113 patients were included in this study. All patients received one injection of 10 ml of 1% lidocaine into the hip joint under fluoroscopy. The duration and effectiveness of the injection were assessed 2 weeks after the injection and at a minimum of 1 year of follow-up. The effect of the injection was graded as 0: unchanged or worse; 1: an effect only on the day of injection; 2: the effect lasted a few days; 3: the effect lasted about a week; and 4: symptom remission. In addition, we recorded whether hip arthroscopic surgery was eventually performed. Results: The effect was rated as 0 in 19 patients (16.8%), as 1 in 30 patients (26.5%), as 2 in 38 patients (33.6%), as 3 in 13 patients (11.5%), and as 4 in 13 patients (11.5%). Seventy-two patients (63.7%) underwent hip arthroscopic surgery. No relationship with patients’ characteristics was found. Conclusion: In total, 83% of patients experienced some effect of the lidocaine injection. Furthermore, 11.5% of patients experienced complete remission of their symptoms.

The Lisbon Agreement on femoroacetabular impingement imaging-part 2: general issues, parameters, and reporting

OBJECTIVES

Imaging assessment for the clinical management of femoroacetabular impingement (FAI) is controversial because of a paucity of evidence-based guidance and notable variability among practitioners. Hence, expert consensus is needed because standardised imaging assessment is critical for clinical practice and research. We aimed to establish expert-based statements on FAI imaging by using formal methods of consensus building.

METHODS

The Delphi method was used to formally derive consensus among 30 panel members from 13 countries. Forty-four questions were agreed upon, and relevant seminal literature was circulated and classified in major topics to produce answering statements. The level of evidence was noted for all statements, and panel members were asked to score their level of agreement (0-10). This is the second part of a three-part consensus series and focuses on 'General issues' and 'Parameters and reporting'.

RESULTS

Forty-seven statements were generated and group consensus was reached for 45. Twenty-five statements pertaining to 'General issues' (9 addressing diagnosis, differential diagnosis, and postoperative imaging) and 'Parameters and reporting' (16 addressing femoral/acetabular parameters) were produced.

CONCLUSIONS

The available evidence was reviewed critically, recommended criteria for diagnostic imaging highlighted, and the roles/values of different imaging parameters assessed. Radiographic evaluation (AP pelvis and a Dunn 45° view) is the cornerstone of hip-imaging assessment and the minimum imaging study that should be performed when evaluating adult patients for FAI. In most cases, cross-sectional imaging is warranted because MRI is the 'gold standard' imaging modality for the comprehensive evaluation, differential diagnosis assessment, and FAI surgical planning.

KEY POINTS

• Diagnostic imaging for FAI is not standardised due to scarce evidence-based guidance on which imaging modalities and diagnostic criteria/parameters should be used. • Radiographic evaluation is the cornerstone of hip assessment and the minimum study that should be performed when assessing suspected FAI. Cross-sectional imaging is justified in most cases because MRI is the 'gold standard' modality for comprehensive FAI evaluation. • For acetabular morphology, coverage (Wiberg's angle and acetabular index) and version (crossover, posterior wall, and ischial spine signs) should be assessed routinely. On the femoral side, the head-neck junction morphology (α° and offset), neck morphology (NSA), and torsion should be assessed.

Ultrasound and Ultrasound-Guided Hip Injection Have High Accuracy in the Diagnosis of Femoroacetabular Impingement With Atypical Symptoms

PURPOSE

To evaluate the diagnostic value of ultrasound and ultrasound-guided hip injection in the diagnosis of femoroacetabular impingement (FAI) with atypical symptoms.

METHODS

We evaluated consecutive patients diagnosed with FAI and with atypical symptoms who underwent ultrasound-guided hip injection between January 2017 and February 2019. All patients underwent systematic physical examination, ultrasound examination, magnetic resonance imaging (MRI) examination, and ultrasound-guided injection before surgery. Patients with positive response to ultrasound-guided hip injection were recommended to undergo arthroscopic surgery to treat intra-articular pathology. Sensitivity, specificity, accuracy, and positive predictive value (PPV) of ultrasound and MRI were calculated by using arthroscopic surgery as the gold standard. The accuracy of ultrasound-guided hip injection was recorded. Preoperative and postoperative patient-reported outcomes included visual analog scale for pain and modified Harris Hip Score.

RESULTS

A total of 78 patients with atypical symptoms were diagnosed with FAI. Among these 78 patients, 50 patients had positive responses to injection and 28 patients had negative responses to injection. A total of 36 patients finally underwent arthroscopic surgery. Response to the ultrasound-guided intra-articular injection was 91.7% accurate for detecting the presence of intra-articular abnormality. There were no complications of injection in any of the patients. The sensitivity, PPV, and accuracy by ultrasound diagnosis of cam impingement were 82.9%, 96.7%, and 80.6%, respectively. The sensitivity and accuracy by ultrasound diagnosis of anterosuperior labral tear were both 72.2%. For MRI diagnosis of cam impingement, the sensitivity, PPV and accuracy were 72.2%, 96.3%, and 74.3%, respectively. For MRI diagnosis of labral tear, the sensitivity and accuracy were both 88.9%. Thirty-four patients (94.4%) surpassed the minimal clinically important difference, and 33 patients (91.7%) achieved the patient acceptable symptomatic state.

CONCLUSIONS

Ultrasound and ultrasound-guided hip injection have high accuracy in the diagnosis of femoroacetabular impingement with atypical symptoms.

LEVEL OF EVIDENCE

IV, case series.

Relationship of the Pelvic-Trochanteric Index with greater trochanteric pain syndrome

OBJECTIVES

This study aimed to correlate a higher Pelvic-Trochanteric Index (PTI) with an increased varus of the femoral neck with greater trochanteric pain syndrome (GTPS). The secondary objective was to check whether the pelvic width changes with age.

METHODS

A prospective study was conducted to compare female patients diagnosed with GTPS (case group) with asymptomatic female participants (control group) from March 2011 to June 2017. On an anteroposterior pelvic radiograph, lines were drawn by two radiologists, and the PTI (ratio of the distance between the greater trochanters and distance between the iliac crests) was defined and the femoral neck-shaft angle was measured.

RESULTS

Data collected based on radiographs of 182 female patients (cases) and 150 female participants (controls) showed that the mean PTI was 1.09 (SD=0.01) in the case group and 1.07 (SD=0.01) in the control group (p<0.05), regardless of age. The distance between iliac crests increased with age (p<0.05) in symptomatic and asymptomatic individuals. It was also found that the mean femoral neck-shaft angle was 130.6° (SD=0.59) and progression of the varus angulation occurred with age in both groups, with a significance level of 5%.

CONCLUSIONS

The PTI was higher in patients with GTPS. The femoral neck-shaft angle does not differ between individuals with and without GTPS; however, it does decrease with age. The pelvic width tends to increase with aging in symptomatic or asymptomatic individuals; therefore, the increase in the pelvic width and decrease in the femoral neck-shaft angle can be interpreted as normal in aging women, which could alter the biomechanics of the hips and pelvis.

A Rare Benign Tumor With Diagnostic Difficulties: Synovial Chondromatosis

In this article, we present a case of a 47-year-old male patient presenting with an insidious onset of hip pain and loss of range of motion. The patient was initially treated conservatively to no avail. Detailed investigations included magnetic resonance imaging of the left hip which revealed a synovitis. Blood results were unremarkable apart from moderately raised inflammatory markers. Differential diagnoses of both intra- and extra-articular hip pain were ruled out and the patient treated for a preliminary diagnosis of psoriatic arthritis for a total of six months. Persistent pain resulted in a re-visit of the diagnosis and further clinical evaluation. This time, an X-ray of the hip revealed calcification at the joint. A computed tomography followed and revealed synovial thickening and intra-articular calcification. A biopsy was consistent with primary synovial chondromatosis (SC). Open synovectomy was performed approximately one year after the onset of symptoms. This case emphasizes the importance of re-visiting initial evaluations and diagnoses when faced with a difficult case of persistent hip pain so to avoid misdiagnosis and unnecessary pharmacological treatment. In view of its rarity and diagnostic challenges, future work on SC should concentrate on gathering data which can be used to produce a diagnostic algorithm.

Integrating Osteopathic Manipulative Treatment and Injections in the Diagnosis and Management of a Hip Labral Tear

Hip pain in adults is a common complaint. Secondary processes can often mask underlying conditions, prolonging the course to diagnosis and definitive treatment. In this case, a 74-year-old man presented to an outpatient clinic after 6 weeks of right hip pain that began upon initiation of a rehabilitation program following coronary artery bypass graft surgery. Various imaging and treatment modalities (including radiography, osteopathic manipulative treatment, injection of the greater trochanteric bursa, L2-3 paravertebral block, magnetic resonance imaging, and intra-articular hip injection with 1% lidocaine) ultimately led to the definitive diagnosis of a labral tear. This case report highlights how a comprehensive osteopathic approach was used to evaluate and treat a patient with persistent unilateral hip pain because of an acetabular labral tear, associated psoas syndrome, and trochanteric bursitis, all within 2 months and with a positive clinical outcome.

Prevalence of Hip or Groin Pain in Adolescents: A Systematic Review and Meta-Analysis

Musculoskeletal pain is a common cause of pain in adolescence and can be an important predictor of future pain. The prevalence of hip or groin pain that could potentially affect different adolescent populations has not yet been systematically reviewed. This systematic review aimed to determine the prevalence of hip or groin pain in this population. Five electronic databases were searched until January 2019 for eligible studies that included males and females 13 to 19 years of age. Study selection, data extraction, and risk of bias assessments were completed by 2 independent researchers. Based on inclusion criteria, 8 population-based, 8 clinical, and 4 sports populations were included. Studies were conducted in Europe, North America, and Australia. The prevalence was dichotomized into "0 to 3 months" and "3 months and above." Meta-analyses were performed to estimate the prevalence from 0 to 3 months, and individual estimates were reported for studies of 3 months and above. The overall prevalence of hip or groin pain in all adolescents from 0 to 3 months was 12% (95% confidence interval [CI] 6%, 23%) based on 10 studies, and was 7% (95% CI 6%, 10%) based on 7 population studies. Caution should be applied to these estimates due to substantial study heterogeneity. The pain prevalence in cerebral palsy from 0 to 3 months based on 4 studies was 13% (95% CI 10%, 15%). Individual prevalence estimates were 6% and 31% in obese and 4% in hypermobility populations, respectively, and ranged from 6% to 100% in 4 sports studies. The validity of these estimates is compromised by poor methodological quality.

The dimensions of the hip capsule can be measured using magnetic resonance imaging and may have a role in arthroscopic planning

PURPOSE

The purpose of this study was to systematically evaluate the dimensions and thickness of the hip joint capsule. Secondarily, the study assessed whether there were any described correlations between capsule thickness and stability of the hip joint.

METHODS

Four databases (PubMed, Ovid [MEDLINE], Cochrane Database, and EMBASE) were searched from database inception to May 2018, and two reviewers independently and in duplicate screened the resulting literature. Methodological quality of all included papers was assessed using the Methodological index for non-randomized studies (MINORS) criteria. Mean differences were combined in a meta-analysis using a random effects model when possible.

RESULTS

A total of 14 studies (1 level I, 1 level II, 4 level III, 5 level IV) were identified including 796 patients (1013 hips) with a mean age of 39.5 years (range 2-95). Of the included patients, 55.2% were female and they were followed up for a mean of 7.6 months (range 1-12.5 months). The thickness of the capsule was measured in cadaveric specimens, ultrasound, and magnetic resonance imaging (MRI), with MRI measurements reported most consistently and with the least variation. Mean thickness of the anterior capsule in patients without hip disease on MRI ranged from 4.4 and 4.7 mm. Mean thickness of the anterior capsule in patients with FAI ranged between 4.9 and 5.0 mm. Males had significantly thicker capsules than females (mean difference = 1.92 mm, 0.35-3.49, P = 0.02). Clinical laxity of the hip joint, as well as female gender was correlated with thinner anterior joint capsules.

CONCLUSION

The thickness of the anterior hip capsule can be measured consistently using MRI. A thinner anterior capsule may be associated with clinical laxity of the hip joint. The relevance of capsular thickness on postoperative instability following hip arthroscopy is poorly understood and warrants further investigation. The thickness of the anterior hip capsule, as measured on MRI, has the potential to be used as part of the clinical decision-making in capsular management strategies.

LEVEL OF EVIDENCE

IV.

[Diagnostic algorithm "FAI and sports hernia" : Results of the consensus meeting for groin pain in athletes]

As a result of the complexity and diversity of diseases in the region of the groin, differentiation of the various soft-tissue and bone pathologies remains a challenge for differential diagnosis in routine clinical practice. In the case of athletes with pain localized in the area of the groin, femoroacetabular impingement (FAI) and athlete's groin must be considered as important causes of the groin pain, whereby the common occurrence of double pathologies further complicates diagnosis. Despite the importance of groin pain and its differential diagnoses in everyday clinical practice, there has been a lack of recognized recommendations for diagnostic procedure to date. To this end, a consensus meeting was held in February 2017, in which a group composed equally of groin and hip surgeons took part. With the formulation of recommendations and the establishment of a practicable diagnostic path, colleagues that are involved in treating such patients should be sensitized to this issue and the quality of the diagnosis of groin pain improved in routine clinical practice.

CrossFit-related hip and groin injuries: a case series

To provide descriptive data on injury presentation and treatment and to identify risk factors for requiring surgical treatment for athletes presenting with CrossFit-related hip and groin injuries. CrossFit-related injuries (n = 982) were identified within a single hospital system from 2010 to 2017, with 83 (8.5% of total) identified hip or groin injuries. Patient demographics, injury diagnosis, surgical procedure and rehabilitation were assessed. Independent predictors of requiring surgery were analyzed via multivariate logistic regression analysis. Patients with hip or groin injuries were more often female (hip injuries: 63%; all injuries: 50%; P < 0.001) with mean age 34.3 years (standard deviation 10.9). Median symptom duration was 4 months with 70% reporting insidious onset. Most common diagnoses were femoral-acetabular impingement syndrome (34%), hamstring strain (11%), non-specific hip/groin pain (imaging non-diagnostic) (11%), hernia (7%) and iliotibial band syndrome (6%). Most (90%) required physical therapy (median 2 months). Surgery occurred in 24% (n = 12 hip arthroscopy, n = 5 inguinal hernia repair, n = 3 total hip arthroplasty), with 100% return to sport after arthroscopy or hernia repair. The only predictor of surgery was complaint of primarily anterior hip/groin pain (82% surgical patients, 46% non-surgical) (odds ratio 5.78, 95% confidence interval 1.44-23.1; P = 0.005); age, sex, body mass index, symptom duration and symptom onset (insidious versus acute) were non-significant (P > 0.25). CrossFit athletes with hip and groin injuries often present with prolonged symptoms with insidious onset. Most patients require several months of physical therapy and approximately one quarter require surgery. Patients presenting with primarily anterior hip/groin pain are at increased risk for requiring surgery.

LEVEL OF EVIDENCE

IV, case series.

Acute Traumatic Tear of the Gluteus Medius and Gluteus Minimus in a Marathon Runner

Background: Tears of the gluteus medius and gluteus minimus are common causes of chronic lateral hip pain in the middle-aged population. These tears are postulated to occur after chronic degeneration of the muscle-tendon unit. The majority of these patients have a long history of peritrochanteric pain. Acute traumatic tear of the gluteus medius and gluteus minimus in otherwise asymptomatic patients is rare but can occur.

Case Report: We report the case of a 78-year-old male marathon runner with acute traumatic tear of the gluteus medius and gluteus minimus. After conservative management (physical therapy, a nonsteroidal antiinflammatory drug for pain, and cortico-steroid and local anesthetic injection) failed, the patient underwent operative repair. The surgery was successful, and the patient returned to his preinjury lifestyle 6 months postoperatively with no limitations.

Conclusion: In most cases, chronic injuries are far more common than acute tears. Because of the nonspecific and slowly progressive symptoms, patients are often misdiagnosed with radiculopathy, osteoarthritis, or trochanteric bursitis. Patients typically present to the clinic with an insidious onset of dull pain over the lateral hip. This pain is often worse when lying on the affected side. Certain gluteal-focused movements, such as climbing stairs, may exacerbate the pain. To our knowledge, our report is only the third case of acute traumatic tear of the gluteus medius and gluteus minimus reported in the literature.

Athletic pubalgia misdiagnosed as lumbar radiculopathy - A case report

Background:

Athletic pubalgia is a painful complex syndrome encountered by many athletes involved in sports. Multiple pathologies often coexist, and many systems can refer pain to the groin. The current case reflects the failure to distinguish pubalgia from lumbar radiculopathy.

Case Description:

Originally, a 47-year-old male with left-sided inner thigh pain was diagnosed as having a L3-4-disc herniation and spinal stenosis; he underwent a L3-4 and L4-5 laminectomy/discectomy. For 2 years postoperatively, the pain persisted. Ultimately, he underwent surgical reinsertion of the adductor muscle and experienced immediate and sustained pain relief.

Conclusion:

This case report highlights how pubalgia may be misdiagnosed as a lumbar disc herniation and may inadvertently lead to unnecessary lumbar surgery.

Concurrent validity of a patient self-administered examination and a clinical examination for femoroacetabular impingement syndrome

Objective

Telehealth has been established as a viable option for improved access and timeliness of care. Physician-guided patient self-evaluation may improve the viability of telehealth evaluation; however, there are little data evaluating the efficacy of self-administered examination (SAE). This study aims to compare the diagnostic accuracy of a patient SAE to a traditional standardised clinical examination (SCE) for evaluation of femoroacetabular impingement syndrome (FAIS).

Methods

75 patients seeking care for hip-related pain were included for participation. All patients underwent both SAE and SCE and were randomised to the order of the examinations. Diagnostic accuracy statistics were calculated for both examination group for a final diagnosis of FAIS. Mean diagnostic accuracy results for each group were then compared using Mann-Whitney U non-parametric tests.

Results

The diagnostic accuracy of individual SAE and SCE manoeuvres varied widely. Both SAE and SCE demonstrated no to moderate change in post-test probability for the diagnosis of FAIS. Although low, SAE demonstrated a statistically greater mean diagnostic accuracy compared with the SCE (53.6% vs 45.5%, p=0.02).

Conclusion

Diagnostic accuracy was statistically significantly higher for the self-exam than for the traditional clinical exam although the difference may not be clinically relevant. Although the mean accuracy remains relatively low for both exams, these values are consistent with hip exam for FAIS reported in the literature. Having established the validity of an SAE, future investigations will need to evaluate implementation in a telehealth setting.

Sacroiliac Pain: Structural Causes of Pain Referring to the SI Joint Region

BACKGROUND

The currently reported incidence of primary sacroiliac joint (SIj) pathology ranges from 15% to 30%. The differential diagnosis of SIj region pain includes pain generated from the lumbar spine, the SIj, and the hip joint. The origins of SIj dysfunctions are controversial and pain generation from this joint has been questioned.

PURPOSE

Retrospectively analyze the relative incidence of lumbar spine, SIj, and hip joint etiologies in patients complaining of ≥50% SIj region pain.

STUDY DESIGN

This is a retrospective cohort case series.

METHODS

Inclusion criteria: chief complaint SIj pain (≥50% of overall complaint). In total, 124 patients charts were reviewed from a single spine surgeon's clinic. All patients were evaluated by the same 2 practitioners and all cases were reviewed for clinical examination findings, diagnostic tests performed, final diagnosis, treatment, and clinical follow-up.

RESULTS

After complete diagnostic workup, 112 (90%) had lumbar spine pain, 5 (4%) had hip pain, 4 (3%) had primary SIj pain, and 3 (3%) had an undetermined source of pain upon initial diagnosis. SIj pain generation was confirmed via fluoroscopy-guided diagnostic injections. Following designated treatment, 11 (9%) patients returned to clinic at an average of 2.4 years complaining of continued/recurrent SIj region pain. Further investigation revealed 6 patients had confirmed pain generation from the lumbar spine, 3 patients had confirmed pain generation from the SIj, and 2 patients had undetermined sources of pain.

CONCLUSIONS

The SIj is a rare pain generator (3%-6%) in patients complaining of ≥50% SIj region pain and is a common site of referral pain from the lumbar spine (88%-90%). Clinicians ought to quantify areas of pain (via percent of overall complaint) when interviewing their patients complaining of low back pain to distinguish potential pain generators. Recommended breakdown of areas of interest include axial low back, SIj region, buttock/leg, groin/anterior thigh.

Patient-reported outcome and muscle-tendon pain after periacetabular osteotomy are related: 1-year follow-up in 82 patients with hip dysplasia

Background and purpose - Larger prospective studies investigating periacetabular osteotomy (PAO) with patient-reported outcome measures developed for young patients are lacking. We investigated changes in patient-reported outcome (PRO), changes in muscle-tendon pain, and any associations between them from before to 1 year after PAO. Patients and methods - Outcome after PAO was investigated in 82 patients. PRO was investigated with the Copenhagen Hip and Groin Outcome Score (HAGOS). Muscle-tendon pain in the hip and groin region was identified with standardized clinical tests, and any associations between them were analyzed with multivariable linear regressions. Results - HAGOS subscales improved statistically significantly from before to 1 year after PAO with effect sizes ranging from medium to very large (0.66-1.37). Muscle-tendon pain in the hip and groin region showed a large decrease in prevalence from 74% (95% CI 64-83) before PAO to 35% (95% CI 25-47) 1 year after PAO. Statistically significant associations were observed between changes in HAGOS and change in the sum of muscle-tendon pain, ranging from -4.7 (95% CI -8.4 to -1.0) to -8.2 (95% CI -13 to -3.3) HAGOS points per extra painful entity across all subscales from before to 1 year after PAO. Interpretation - Patients with hip dysplasia experience medium to very large improvements in PRO 1 year after PAO, associated with decreased muscle-tendon pain. The understanding of hip dysplasia as solely a joint disease should be reconsidered since muscle-tendon pain seems to play an important role in relation to the outcome after PAO.