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Making the Right Diagnosis

Making the Right Diagnosis. Symposium: Joint Preservation Hip Surgery – How to Avoid and Treat Complications and Failures Wednesday, February 16 th , 2011 Bryan T. Kelly, MD Co-Director Center for Hip Pain and Preservation. Bryan T. Kelly, MD Hospital for Special Surgery

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Making the Right Diagnosis

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  1. Making the Right Diagnosis Symposium: Joint Preservation Hip Surgery – How to Avoid and Treat Complications and Failures Wednesday, February 16th, 2011 Bryan T. Kelly, MD Co-Director Center for Hip Pain and Preservation

  2. Bryan T. Kelly, MD Hospital for Special Surgery Disclosure: I DO NOT have a financial interest in any commercial products or service presented in this lecture AND DO NOT INTEND to discuss off label or investigational use of products or services.

  3. Types of financial relationships and the companies with whom I have relationships are as follows: Pivot Medical, Inc.: Consultant Smith & Nephew: Educational Consultant A2 Surgical: Consultant

  4. Origin of hip pain can be difficult to identify MUST DISTINGUISH BETWEEN INTRA- AND EXTRA-ARTICULAR PAIN Diagnostic Dilemma

  5. Labral Tears Hypertrophic tears (dysplasia) Hypotrophic labra Chondral Injury Focal chondral defects AVN Ligamentum Teres Tears Partial Complete Femoroacetabular Impingement CAM Pincer Synovitis Loose Bodies Tumors Synovial chondromatosis PVNS “Intraarticular Disorders”

  6. Capsular Problems Hip Instability Adhesive Capsulitis Snapping Hip Internal Snapping Hip External Snapping Hip Lateral Hip Pain Recalcitrant Trochanteric Bursitis Gluteus Medius / Minimus Tears Pubic Pain Osteitis Pubis Chronic adductor strain Sports Hernia Tendonitis / Avulsion Injuries Nerve Compression Meralgia Paresthetica (LFCN) Piriformis Syndrome (Sciatic n.) Ilioinguinal n. Iliohypogastric n. Genitofemoral n. “Extraarticular Disorders”

  7. History & Physical Exam

  8. History • Mechanism of Injury: • Duration of Pain: • Location of pain: • Primary • Secondary • Aggravating Activities • Sitting • Standing • Walking • Sports • Clicking / Catching / Locking • Internal (Psoas) • External (ITB) • Intraarticular • Previous Surgery: • Hip Arthroscopy • Pelvic Osteotomy • Open Hip Dislcoation • Hernia Surgery • Back Surgery • Others • Physical Therapy: • Duration • Improvement ( Yes / No )

  9. Minimum Clinical Exam • Limp ( Yes No ) • BMI • ROM: • IR @ 90 degrees flexion • Flexion • External Rotation • Extension • Abduction in supine position • Craig’s Test • Provocative Pain • Impingement (FADIR) • Sub-Spine Impingement Sign (Anterior Pain with Flexion) • Superolateral impingement (Anterolateral pain with flexion / ER) • Trochanteric Pain Sign (Posterolateral pain in FABER) • Lateral Rim Impingement (Pain with abduction) • Instability (Extension / ER with Anterior Pain) • Posterior Impingement (Extension / ER with Posterior Pain) • Ischio-Femoral Impingement Sign (Post pain with Ext / IR)

  10. Normal Passive Hip ROM • Adduction 30˚ • Abduction 45˚ • Flexion 110˚ • Extension 0˚ • IR 30˚ • ER 50˚

  11. How do you assess ROM • IR Block Test

  12. Provocative Pain tests • Impingement test • Flexion, adduction, internal rotation • Anterior or anteromedial pain with anterior and anterolateral impingement

  13. Provocative Pain tests • Subspine Impingement Sign • Straight Flexion • Anterior pain from inferior impingement or sub-spine impingement

  14. Provocative Pain tests • Superolateral Impingement • Flexion, external rotation • Anterolateral pain with superior or superolateral impingement

  15. Provocative Pain tests • Trochanteric Pain Test • Flexion, abduction, external rotation • Posterolateral pain from trochanteric irritation

  16. Provocative Pain tests • Lateral Rim Impingement • Straight Abduction with neutral rotation • Lateral pain from lateral rim impingement

  17. Provocative Pain tests • Instability Test • Extension, external rotation • Anterior hip pain

  18. Provocative Pain tests • Posterior Impingement • Extension, external rotation • Posterior hip pain

  19. Minimum Clinical Exam • Strength • Hip Flexion • Adduction • Abduction • Palpation Pain • Central Pubic • Resisted Sit-Up • ASIS • Hip Flexors • Abductors • Adductors • Proximal Hamstrings • Ischium • Peritrochanteric Space Exam • Pain over trochanter • Anterior • Lateral • Posterior • Weakness in Abduction • Knee Extended • Knee Flexed • Snapping

  20. COMPREHENSIVE EXAMINATION OF THE ADULT HIP • Five points for five body positions • STANDING • SITTING • SUPINE • LATERAL • PRONE • ADDITIONAL TESTS AS NEEDED

  21. STANDING EXAMINATION • General • Laxity, Body Habitus, Posture • Gait • Swing, Stance, Foot Progression, Pelvis • Spine • Lateral, Posterior, Scoliosis, Lordosis • Pelvis • Shoulder height, Iliac Crest • Trendelenburg Test • Positive, Shift or Weakness

  22. STANDING EXAMINATION • Gait • Trendelenburg • Abductor lurch • Antalgic • Foot progression angle • Excessive External Rotation • Excessive Internal Rotation • Short Leg Limp

  23. STANDING EXAMINATION • Trendelenburg Test • Weak abductors lead to the pelvis dropping to the unsupported side • With Compensation • Severe weakness the pt is unable to lift the opposite side without leaning toward the wt bearing limb to decrease the moment arm.

  24. SEATED EXAMINATION • Neurologic • DTRS, Sensory, Motor, Straight Leg Raise • Circulation • DP, PT, Popliteal • Skin • Lymphatic • IR/ER

  25. SUPINE EXAMINATION • Passive ROM • Flexion, Abduction, Adduction, IR, ER • Strength Testing • Flexion, Adduction, Abduction • Provocative Pain Test • Pubalgia Testing • Special Tests • Thomas Test • Patrick / Faber’s • Instability Test (extension / ER)

  26. LATERAL EXAMINATION • Palpation GT, ABDUCTORS, SI, ISCHIAL BURSAE • Obers Test FLEXION, EXTENSION • Passive / Active ROM MEDIUS / MAX • FADDIR IMPINGEMENT • Lateral Rim Impingement

  27. Palpation 1 SI 2 Greater Trochanter Medius, Minimus Maximus origin 3 Ischial Tuberosity 4 Piriformis

  28. Lateral Hip Anatomy Gluteus Medius Gluteus Minimus

  29. Dwek J. Pfirrmann C. Stanley A. Pathria M. Chung CB. MR imaging of the hip abductors: normal anatomy and commonly encountered pathology at the greater trochanter. Magnetic Resonance Imaging Clinics of North America. 13(4):691-704, vii, 2005 Nov • 4 facets, 3 have distinct insertions

  30. OBERS TEST ILIOTIBIAL BAND IN EXTENSION

  31. Obers in Flexion Tight Maximus contribution Touch the table o/3 3=above neutral

  32. Grade 0/5

  33. Grade 0/5 Active ABD Medius vs Max Strength

  34. PRONE EXAMINATION • Craig’s Test • Femoral anteversion • Ely’s • Rectus Femoris Contracture • Hyperextension • Lumbar Spine • Palpation • Paravertebral muscles, spinous process

  35. Anteverted 82.6% Retroverted 17.2% Craigs Test Elys

  36. Anatomic Approach to Evaluation of the Non-Arthritic Hip • History • Clinical Exam • Radiographic / Mechanical Diagnosis • Intra-articular Damage Pattern • MRI / Arthrogram • Intra-operative findings

  37. Layer 1: Osteochondral LayerStructures: Femur, Pelvis, AcetabulumPurpose: Joint congruence and normal osteo / arthro kinematics • Dynamic Impingement • Cam Impingement • Rim Impingement • Femoral Retroversion • Femoral Varus • Static Overload • Acetabular Dysplasia • Femoral Anteversion • Femoral Valgus

  38. Radiographic Indices: Mechanical Diagnosis Retroversion (15-20o anteversion) <15o [nml >25o] >15o [nml <10o] Alpha Angle >50o >140 or <120 7.2mm Nml=11.6

  39. CT-Scan: Mechanical Diagnosis

  40. Layer 2: Inert LayerStructures: Labrum, joint capsule, ligamentous complex, ligamentum teresPurpose: Static stability of the joint • Labral Injury • Cartilage Injury • Capsular Injury • Instability • Adhesive capsulitis

  41. MRI

  42. Layer 3: Contractile LayerStructures: All musculature including lumbosacral musculaturePurpose: Dynamic stability • Athletic Pubalgia • Abductor Failure / Pain/ ITB • Proximal Hamstring Syndrome • Hip flexor tendonitis • Psoas dysfunction • Paraspinal dysfunction

  43. Layer 4: Neuromechanical LayerStructures: TLS Plexus, Lumbopelvic structures, LE structuresPurpose: Neuromuscular linking and functional control of the entire segment as it functions within its environment • Nerve compression syndromes • Pain syndromes • Neuromuscular dysfunction • Spine referral patterns

  44. Patient Selection Neuromuscular Research Laboratory University of Pittsburgh Hip loaded pelvis usually rotates over fixed femur creating anterior and medial forces with rotary moments

  45. LABRAL TEARS • Combine these forces with dynamic or static overload to the joint…

  46. Treatment Plan The location and quality of the pain should correspond to the mechanical diagnosis and primary and secondary injury patterns. If they do, then correcting the mechanical problems and primary and secondary injuries should lead to a good outcome….

  47. Thank You

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