Let's see, are you able to share your screen? Yep. There we go. Perfect. There now. Okay. All right, we can see it. Thank you. Great. Okay, so I think this is a great next topic after the lumbar spine is to go on to talking about hip pain. I don't have any disclosures. We're going to talk first about hip anatomy, pain referral patterns, going to physical exam and differential, and then talk about some more of the high yield intra-articular and extra-articular hip problems. This is titled Hip Pain in the Athlete, but for me, the athlete is anyone doing any sort of active sports or activities, so not just our young athletic population that we're talking about today. So for the hip joint, here is basic bony anatomy in the bottom right. The main functions of the hip joint is to, number one, allow mobility of the lower extremity, but also it's really important in transmitting loads from the upper body and spine down through the lower extremities to provide a nice stable base for weight bearing. The stability of the hip joint is provided by the bony structure, but also ligaments and capsules and a lot of muscles around the hip as well. This is looking at the anatomy of the joint, and so you can see the femoral head has been dislocated from the acetabulum here. The femoral head is generally covered by an articular cartilage, and then this ligamentum teres helps to hold the femoral head into the joint and also provides some stability and a little bit of blood supply, and that ligamentum teres is lined by synovium. The acetabulum here is the bony structure, which is then further deepened by the fibrocartilage labrum around the acetabulum, and it's got an inverted U-shaped articular cartilage across the more superior portion, and then inferiorly, the transverse acetabular ligament. This shows a gross anatomy image of what we just saw, so you can see that nice articular cartilage and the inverted U, the acetabular labrum, and then the femoral head here with the nice smooth articular cartilage, and this shows the density of the cartilage in these two images here for both the acetabulum and the femoral head, and note that the most dense part of the cartilage is anterior and superior in both the acetabulum and the femoral head, and that's where the main weight-bearing portion of the joint is. Talk a little bit more about the labrum, so you can see on this coronal cut through the hip here that the blue arrow here is pointing to that labrum, which extends from the bony acetabulum. The labrum, it's important to note that it is thinnest anteriorly, which is where we commonly see teres. The blood supply enters through the capsule, and so only the outer portion of the labrum is vascularized, and so that's important for healing, and it's like many of those other structures in our body with a poor blood supply in that they don't heal well. It's also important to note that there are nociceptive-free endings throughout the labrum, and so it is a pain-generating structure, and important for the structure and integrity of the hip joint, the labrum seals the hip joint and maintains some pressure in there to help to separate the femoral head from that acetabulum just a little bit as well. Coming out from the hip is the hip capsule, and that's what surrounds the hip joint. The capsule is lined by the synovial membrane and reinforced by ligaments. The capsule does come all the way down to this intertrochanteric line and reflects back, and that's important to note if we're thinking about doing an injection to the hip joint. We don't have to try to get a needle in between the femoral head and the acetabulum. All we need to do is just inject whatever we're injecting into the joint into the capsule, and that will then spread throughout the hip joint. So these are the ligaments that support the hip joint. The iliofemoral or Y ligament is across the anterior superior and posterior superior portions of the joint. The pubofemoral inferiorly and more anteriorly, and then the ischiofemoral inferiorly and more posteriorly. When the hip is in an extended sort of neutral position, these ligaments are more twisted as you can see in this image here, which provides a lot of stability, and often you'll hear therapists talking about a patient hanging on their Y ligament, and what that means basically is that they're standing in this neutral position with the hip extended, and it's a very low energy position because that iliofemoral ligament is nice and tight in that neutral extended position and just holds the hip without needing a lot of muscular activity. Now you will note there are a couple of spots here that I've highlighted that are weak spots in the ligaments, and these are the spots that are more prone to allow hip dislocation, and we'll talk about hip dislocations later on, but I want you to have that anatomy image in mind. Okay, so that's the anatomy. Dr. Kirshner just talked about some of these referral patterns and saw the same image in his slides there, which is great, but it's really important to think about this when we're talking about hip pain, and so all the time when I have patients come into clinic, they say I have hip pain, and then they point to their buttock, and we all traditionally think about hip pain as groin pain, and so it's important when a patient says my hip hurts that you know where that pain is coming from. Is it in the groin? Is it lateral? Is it buttock? All of those could be the hip, but it could be other things as well, so it's important to think about lumbar sources, as Dr. Kirshner mentioned previously, the sacroiliac joint, those facet joints, but you can see there's a pretty wide spread of pain that can come from the hip as well, most commonly groin, lateral hip, and buttock, but it can also spread down to the anterior thigh. Hip pain can present only at the knee when it's coming from the hip, which can be tricky, so it's important if you have a patient coming in with pain at the knee that you're also examining their hip, but there are cases of pain distal to the knee as well, and traditionally we're taught the pain is distal to the knee, it's not from the hip, but it can be, so keep that in mind as well. Think about what's most common, but think about those outliers as well. So when you have these patients with hip pain, our physical exam, we always want to make sure we do a good neuro exam, good MSK exam. On your neuro exam, the traditional kind of classic things that we do, we're checking reflexes, sensory testing, strength testing, making sure that we don't have a lumbar radicular issue, and looking for patterns of weakness as well, especially in those muscles around the hip, which we'll talk about a little bit more later on as well. On your musculoskeletal exam, we always start with inspection, and the things that you want to pay attention to, especially for the hip, is number one, looking at how the patient's walking. Do they have a limp? Is their gait antalgic? Do they have trunk lean? So when they're putting weight on their right leg as they're walking, are they leaning to that right side, or is their pelvis dropping? Do they have a Trendelenburg gait? These can be signs of either intrinsic hip pathology or hip abductor weakness. And then you also, in a stationary position, want to look at their alignment of their lumbar spine. Do they have a scoliosis? Are they shifted to one side, which might make you think more of a lumbar issue? Look at their pelvic alignment. Do they have a leg length discrepancy that might be contributing to more hip pain on one side or the other? When you go on to palpation, of course, we're examining the lumbar spine as well. So palpating the long lumbar spine, the posterior superior leg spine over the SI joints, and palpate the lateral hip over the greater trochanter and those gluteal tendons, and then the anterior hip palpating over the iliopsoas to see if that can reproduce any of their pain as well. And with range of motion, important to evaluate both the lumbar spine and the hip. And don't forget when you're looking at the range of motion that movements at the spine and the hip overlap, and that if one is restricted, then the other may be getting more stress as well. So someone's got, maybe they have a history of a lumbar fusion, and they have restricted lumbar motion, and that can put more stress on the hip as well. So specific tests for the hip joint, there's a handful of the more common provocative tests for the hip joint here. First one that's listed there is the FADER, so flexion adduction internal rotation, it's also known as the anterior hip impingement test. And I'll have images of all these on the next slide for those visual learners out there. FABER is the flexion abduction external rotation. And this one is not necessarily specific just to the hip joint, so it's really important to know where the pain is being reproduced, and also then combine that with other physical exam maneuvers to have that help you to determine where the pain's coming from. If you have pain in the SI low back or posteriorly when you do this test, it might indicate more of an SI joint source, although don't forget hip pain can be posterior as well. If you have pain anteriorly in the groin, then that might be more indicative of a hip issue. And if you've got pain laterally with the FABER test, then it might indicate a greater stroke issue. The resisted straight leg race test, or Stinchfield, and then log roll test are a couple of the other ones that we use. If the usual pain is reproduced by these provocative maneuvers, then that helps you to think that the pain is coming from the hip, and then the axial distraction test should alleviate the pain that they usually have from the hip if the pain is coming from their hip joint. So here's images of all of these. So first thing, FABER or Patrick's test, so that's putting a stabilizing force at the contralateral ASIS, and then pushing down at the knee with the hip in the flexed abducted external rotated position, and that again should reproduce their usual pain. That's on the top right, the FADER, which is flexion, adduction, and internal rotation. In the middle here, Stinchfield, that's the resisted active straight leg race, so the patient has their leg up about 20, 30 degrees, and you're putting a downward force and they're pushing up into your hand, and that should reproduce their pain if it's coming from the hip. The log roll is just a very passive test, the patient's just lying with their hip in a neutral position, and the examiner passively, internally, and externally rotates the hip. This one, there's not a whole lot else going on with this test other than moving the hip, so I really like that one, and patients where it's really unclear where their pain's coming from. If this test is positive, it really makes me think the hip. Same thing with the axial distraction test here on the bottom right. If you're pulling on their hip by putting this axial force, and their pain goes away, then that's also one that really makes me think more hip than anything else. When we're talking about those hip abductors like we talked about before, the Trendelenburg test can help you know if they've got weakness in the hip abductors. You can do this one of two ways, either you can have the patient walking and look for that contralateral hip drop, or you can have them just stand on one leg and see if they're able to stabilize the pelvis. If they have trouble doing that, then that can indicate some weakness in those hip abductors. And then the other test that's fairly good for looking at greater trochanteric pain or lateral hip pain is the resisted internal rotation, or what's called the external derotation test. So you put them in a position of external rotation, and then have them actively push into internal rotation as you resist that. Not a test that we hear about a lot, but one that's good for lateral hip pain. Okay, so we're going to move on from exam to talk about differential diagnosis a little bit. I know you guys have heard a bit about this just in the last lecture, talking about the lumbar spine as well. So number one thing when someone's got hip pain is to determine, is this the hip or is it not the hip? If it's the hip, we want to try and sort through is it intraarticular or extraarticular first of all. If it's not the hip, then where's it coming from? Is it the spine or the SI joint? Is it a peripheral nerve issue? Is it referred from pelvic viscera, like a tumor, something else like that? Or in pregnancy, we can think about something like round ligament pain. So when we're talking about the hip specifically, and thinking about intra or extraarticular, there's a lot going on that can cause pain in those areas. The intraarticular list here is a bit shorter than all of the other things extraarticularly that can cause pain. We're going to start with intraarticular here. And the ones that I've got in bold are the ones that we're going to spend a little bit more time talking about. You can see there's a lot going on, even with intraarticular issues, we can kind of sort this into categories. Is this a prearthritic or arthritic hip issue? Is this a bone or vascular issue? Was there trauma? That's a little bit more straightforward and a shorter list if there was a known trauma. Asinovitis or inflammatory issue, an infection. And then in kids and adolescents, they've got their own pathologies, and we're not going to delve into that much today. Okay, so starting with some of these prearthritic conditions, we'll start with FAI syndrome. So femoral acetabular impingement syndrome. And you've probably heard of just this referred to as FAI in the past, but the preferred terminology is actually FAI syndrome. And there was this Warwick Agreement published in 2016, and they recommend use of FAI syndrome and define it as a triad of symptoms, clinical signs, and imaging findings. And so the symptoms that we're looking for for FAI syndrome is generally hip or groin pain, and it's usually motion or position related, but pain could also be in the back, the buttock, or the thigh. And they may have mechanical symptoms like clicking, catching, locking stiffness, restricted motion or giving way, especially if there's labral pathology associated. The clinical signs, so the things that we're looking for on exam would be reduced internal rotation range, especially in a flexed position, positive fade air, which is shown here on the right, which is sensitive but not specific, and they may have weakness in hip girdle muscles. So again, these exam findings, these signs, I'll help you to sort through, but it's not going to tell you that they have FAI syndrome. So that's where imaging comes into play. And when we're talking about diagnosing FAI syndrome, you want to generally see the imaging findings on X-ray, but because X-ray is a two-dimensional view, we don't necessarily always see the pathology on X-rays. And so sometimes we'll look with a CT or MRI to get more information, and the CT gives us a much better picture of the bony morphology, and MRI shows us more detail of the bony morphology, but also can show articular cartilage or labral pathology that can be associated with this impingement pattern. With the X-rays, we're always getting two views, an AP and a lateral, and we'll look at X-rays coming up on the next slide, which can show the CAM or the pincer morphology. And this is another terminology preference, is morphology. So we're talking about morphology and not lesion or deformity or anything like that. We're just referring to these findings on imaging as morphology. And if we have, you know, the positive history and the exam and imaging, but we're still not sure where the pain is coming from, then diagnostic injections into the hip joint can really be helpful. If you put an anesthetic into the joint and it resolves the patient's pain for a short period of time, then that confirms that the pain is of an intraarticular source. If it doesn't, then you're going to go on to look for other things. So FAI morphology. So we have two things that can cause this FAI. One is the CAM, which is increased bone growth at the femoral head-neck junction, and this is usually in the anterior and superior regions of the femoral head-neck. And this leads to a reduction in the femoral head-neck offset. So usually what we want to see is about 20 millimeter offset between the femoral head and the femoral neck. When you get this bony overgrowth in that region, then you'll have less of an offset and often you'll see what we often refer to as a CAM bump there. The other is the pincer morphology, which is bony changes in the acetabulum. And we often just refer to this as kind of overcoverage or overgrowth. Most commonly it's anterior overcoverage. The other thing that can show up with the pincer morphology is retroversion. So a deeper anterior wall of the acetabulum. And you can have a mixed morphology with both CAM and pincer deformities or morphologies. So this is a normal X-ray. I just want you guys to see what a normal, well-done hip X-ray or pelvis X-ray looks like. And so if you look at the distance between the pubic symphysis and the coccyx, it should be about one to three centimeters. This tells you that you've got a pretty straight-on X-ray. It's not angled up or down. And that these obtrator foramens should be symmetric in appearance, which tells us that our X-ray is not oblique. If you've got a well-done X-ray like this, then you can use it to determine the morphology. That's our anterior view that we get. These are showing a couple of the lateral views that you can use to look at the hip. The one on the left here, labeled A, that's a done view, and the hips are flexed and abducted. And B here is a frog leg lateral with the hip abducted. And you also can use a cross table lateral view. But I feel like generally and most commonly what I'm getting in clinic is the frog leg lateral. And this could be really helpful to look for the CAM morphology. You always want to get both the interior AP pelvis and a lateral view. So on x-rays, what do we see with the CAM morphology? How do we measure that? So what you hear about most is the alpha angle. And so to measure the alpha angle, you draw a circle around the femoral head at where it's kind of most round. You draw a line down the center of the head and neck. And then you draw a line from that center point of the femoral head to where you lose the sphericity. So you can see this CAM morphology with the bump here. So that line and this head neck center line, that angle is your alpha angle. And the larger that angle is, the greater the CAM morphology and the more loss of sphericity. Different studies define this in different ways. Some use more than 55 degrees, other use 60 degrees. There hasn't necessarily been one number that's shown to be really predictive of FAI syndrome or a more significant CAM morphology. This is how one of the ways to measure the pincer morphology. This is looking for acetabular overcoverage. Here we're measuring the lateral center edge angle. And so here we take a line across the transverse pelvic axis and then a line perpendicular to that from the center of the femoral head. And then from that femoral head center, we draw a line out to the lateral sore seal, which is at the edge of the acetabulum. This angle is the lateral center edge angle. You can see the larger this angle is, the more overcoverage there would be from the acetabulum. Generally greater than or equal to 40 degrees is positive for pincer morphology. We can also use this measurement for hip dysplasia and under coverage of the femoral head. And usually that's looking at 25 degrees or less. So a really shallow acetabulum would be more of a hip dysplasia, which we'll talk about a little bit later as well. Then the last thing that we're most commonly looking at for pincer morphology is looking for the signs of the anterior overcoverage or retroversion of the acetabulum. And we see this with a crossover sign. And so these lines are showing us the anterior and posterior acetabulum walls. And it takes a bit of a trained eye to see, but you can see along here and here, and they're crossing over right in here. And so that's a sign of a retroverted acetabulum and that is pincer morphology. So here's just a couple of X-ray images showing kind of where you're looking for that, for the pincer, for that overcoverage and the cam, that bump here at the femoral head and neck junction. And then just on an anterior view here, we can see a reduction of the head neck offset with that cam morphology here as well. Okay, so now that we've seen the X-rays with that morphology, it's important to note that these morphologies are very common in asymptomatic individuals. Some studies suggest anywhere between 15 to 40% of the general population. Most studies show that cam morphology is present generally about five times more in men than women. This may, in prior studies, have been from more sports participation for men at these high levels, but some more recent studies are suggesting that these numbers are actually becoming a little bit more even as more women are participating at a higher level in sports. What's interesting to note is that some studies looking specifically at high-level athletes or just athletes in general show that 50 to 90% of these male athletes have some FAI morphology. So really common, not always symptomatic. So that's why we always talk about this. When we talk about FAI, it's not just the imaging findings. It's the combination of hip pain with some physical exam signs and the imaging together. I think this is pretty interesting to talk about the etiology of FAI morphology. And mostly this is talking about the cam morphology is it seems to have, like I said on the last slide, a high association with sports participation, especially at the time of physioclosure, suggesting abnormal development. And so this next slide is going to show kind of what's suggested as a possible etiology for that. And this top is showing just a graphic representation of normal development, and then the bottom developing cam morphology. And then this is showing the same thing, but with x-rays, you can see there's this growth plate in the femoral head. And this is across the top here showing what x-rays would look like with normal development there. So you see a nice development of this femoral head-neck offset. And then the bottom one here showing the cam deformity or cam morphology, where as this growth plate is closing, we get more bone growth there at the head-neck junction, and that leads to that cam morphology. So there's still some research to be done, and we don't know how significant this is necessarily, but it's important to note that this may be how this develops. So now that we know what this FAI syndrome is, how do we manage it? So the main recommended management is conservative activity modification, so rest and avoiding those positions of impingement, so often end ranges of flexion, internal rotation. Rehab, so we want to maximize neuromuscular control around the hip. And studies have also showed maybe better outcomes with adding in trunk stabilization, so planks and bird-dog exercises as well, not just focusing on the hip-strengthening exercises. If needed, steroid injections can also be done, especially in these young individuals. We probably want to limit their exposure to steroids, but most of our surgeons will say at least one steroid injection is reasonable. It's not something you want to continue to repeat over time, but something that can be very reasonable to help to reduce pain. One study looking at FAI syndrome showed about 70% of individuals, and these were young athletes, I think between the age of 10 and 21, got better with conservative exercise treatment. Another 12% or so got better with a steroid injection, and then about 10% went on to surgery. So with conservative management, we can actually get pretty good improvement in symptoms. If not improving with conservative management, surgery is an option, and the surgery that's done is an osteoplasty, and that's basically just shaving down that bony overgrowth or impingement. That can be both the acetabulum and the femoral head-neck junction, depending on where the morphology changes are. Labral repair is done if there is an associated labral tear. Surgery is not recommended, though, in those with more significant osteoarthritis changes, so greater than a tonus grade one, or if they've got less than two millimeters of joint space, or if they're over the age of 60. And the reason that they don't recommend surgery in this population is because usually within two to five years, these individuals would go on to a hip arthroplasty or hip replacement, and so the FAI surgery is not really helpful in the long run. Why do we talk about surgeries? Because there was this big push a while back for surgery in these individuals to try to prevent the progression to osteoarthritis, because we know that this FAI morphology, or FAI syndrome, these individuals, are at increased risk for labral tears, cartilage loss, and osteoarthritis. But we don't really know if surgery does prevent that progression of osteoarthritis, so currently the practice is surgery for these individuals if they're symptomatic and not improving with conservative management. Surgery is not recommended simply as a preventative measure, so important to note that. Okay, so shifting from FAI to now developmental dysplasia. So we talked about this on, we were talking about the lateral center edge angle. This is an undercovered hip, and so generally you have a shallow and abnormally aligned acetabulum. Can also be associated with coccyvalgus, so an increased angle between the femoral neck and femoral shaft, and excessive antiversion of the hip. This contributes to an unstable hip, and they often have weakness due to altered biomechanics. It can be commonly seen in the CP population. The treatment depends on the age of the individual. So often you hear about the hip dysplasia in infants, and you think about that screening exam that is always done in an infant to make sure that their hips don't dislocate or sublux. In the young individuals, you can generally treat with splinting or casting because they're young enough for that hip to maybe develop more of a normal coverage pattern. But when they're older and it's skeletal maturity, it's not going to change. And so in that population, generally they need an osteotomy, which is a big surgery to realign the acetabulum. So hopefully conservative management can work, but if not, then they can go on to surgery if their hip is really unstable and they're having a lot of issues and have had associated labral tears and other issues with it. Okay, so moving on to labral tears. So you've heard me talk about this with both FAI and hip dysplasia. Those are factors that can increase the risk for labral tear, but labral tears can happen without those pathologies or morphology changes as well. Labral tears account for up to about 22% of athletes with groin pain and half of patients with mechanical symptoms and hip pain. So locking, clicking, catching, give way, generally presenting pain in the anterior hip or groin, but pain related to a labral tear can be in the buttock as well. So this was a study looking at individuals with known labral tears. They had a positive diagnostic injection before going on to surgery. And this is talking about where the patients noted their pain on an intake form. So patients were given this diagram with these different circles and they were asked to kind of note which of those circles they felt their usual hip pain. And I've colored in the areas here in green where it was most common that the patients had pain related to their labral tear and the central groin and lateral hip being the most common. And then I've X'd out the areas where patients really didn't report pain. So being the ischial tuberosity, the anterior thigh and the pubic symphysis. And then these other areas that I haven't colored in, not statistically significant. So those are areas where there could be pain, but again, most commonly anterior or lateral hip, less commonly midline and ischial tuberosities and thighs. Labral tears can be an acute injury or due to repetitive microtrauma. And that again could be in the setting of FAI or hip dysplasia. There can be a tear within the labrum itself or a detachment of the labrum from the cartilage. We generally diagnose this with an MR arthrogram. And that can be done either after a diagnostic hip injection to confirm intraarticular pathology, or if your suspicion is pretty high that they've got a labral tear, you can go ahead and do the MR arthrogram without a first diagnostic hip injection. But you can have the radiologist, and they generally always do this anyway, put anesthetic in with their arthrogram injection, and then ask the patient to pay attention to their pain. And does it get better right after the arthrogram injection? But hip arthroscopy is still the gold standard. MRI can miss labral tears, even with an arthrogram or a 3-Tesla high resolution MRI. Treatment for this, kind of same as the other things we've talked about so far. Start with conservative management, so avoiding those provocative positions. We wanna improve their neuromuscular control around the hip. Try some gait retraining to minimize hip extension, so minimizing putting stress at that anterior hip where it's most common to have those tears. Surgery can be done when indicated, again, generally not done in a population with more significant osteoarthritis. So if they've got significant cartilage wear, osteophytes, things like that, generally not thinking about surgery for the labral tear in that population. Okay, so those things that we talked about were all pre-arthritic hip conditions. So all of those can lead to hip osteoarthritis. Hip osteoarthritis can also just come on due to use, due to genetics, other factors as well. So like the FAI morphology, we see it in a lot of people, it's not always symptomatic. Radiographic hip osteoarthritis is present in about a quarter of adults over the age of 45, but symptomatic only about 10% of adults over the age of 45. So just because we see it on imaging doesn't mean it's the source of the pain as well. Like other hip issues, patients present usually pain in the groin, anterior thigh, lateral thigh, or buttock. And they'll demonstrate the C sign, which is shown in the picture, and that's the patient, when you ask them where their pain is, that's what they say. And that's basically them indicating that the pain is deep within the hip, kind of felt anterior, posterior, lateral, it's just deep inside. If I have a patient, usually if they're pointing more laterally, I'll say, okay, is this something that you can put your hand on? Is it more close to the surface or does it feel deep? And if it's something like hip osteoarthritis or other intra-articular pathology, generally we'll say it's deep in the hip. So generally you're gonna have pain with activity and weight bearing, pain with sitting, because they're getting into more of an end range of hip flexion and then getting in and out of the car because of the hip flexion and hip rotation. On exam, pain with those hip provocative maneuvers, and they may have loss of range of motion, especially if more advanced osteoarthritis. X-rays are used to confirm the diagnosis. And then treatment, as it is for other joints with osteoarthritis, conservative measures. So modifying activity, doing physical therapy, strengthening, recommending more lower impact exercise, use of a cane or other assistive device as needed, weight loss if indicated, and if they have a BMI in the overweight or obese range, especially if they are obese. Medication use, there's nothing magical here. You know, glucosamine and chondroitin maybe helps a little bit with pain. Anti-inflammatories, NSAIDs and acetaminophen as over-the-counter medications. They're not something you want your patients taking long-term so that they need to take those when their pain is flared up, great to use those sorts of things. Topical agents don't really help for the hip because the hip is too deep for those topical agents to penetrate. And then tramadol or opioids really only if needed. And obviously we try and stay away from those types of medications as much as possible. Injections into the hip can be helpful. Most commonly, that's corticosteroids. Visco supplementation has been used off-label. That's pretty rare to see that used. And then platelet-rich plasma and other injections can be done as well. Of course, those being out-of-pocket expenses to your patient. And then once the patient's osteoarthritis is advanced enough and they're symptomatic enough, then generally they'll go on for a joint replacement. And again, no indication for hip arthroscopy unless they have very, very mild arthritis and have a labral tear that needs to be repaired. Here's an X-ray. One of my patients with pretty severe osteoarthritis. We can see all the classic X-ray findings. So joint space narrowing, subchondral cysts, subchondral sclerosis, and osteophyte formation. Pretty significant arthritis here. And then this is what it would look like post-arthroplasty. Okay, so switching gears to generally different population. Talk about femoral neck stress fractures. So these are usually a gradual onset of pain associated with an increase in training intensity. Pain is worsened by activity. You have pain at the extremes of hip motion, especially internal rotation. On imaging, X-rays are usually negative early on. So an MRI or bone scan can really be helpful in helping you to find that fracture. This is showing stress fracture here, the inferior part of the femoral neck. With these stress fractures, it's important to note where the stress fracture is. Is it on the superior or tension side? If so, that's a high risk for a complete fracture. Those patients need to be treated with strict non-weight bearing or may just go on to early surgery. If it's on the inferior or compression side, that's low risk. So treated with non-weight bearing and then gradual progression of weight bearing, usually at least six weeks before they begin their progression back to running or other sports activities. So just, this is a really important high yield fact here, superior tension side, high risk, inferior compression side, low risk. All right, another bony issue, avascular necrosis. This is due to a disruption of the blood supply. You can have collapse of the femoral head. So the graphic here shows kind of the stages. So stage one, the bony morphology is normal. Stage two, you start to get disruption. Stage three, collapse. And then stage four, you start to get disruption into the acetabulum and osteoarthritis. Risk factors, there's a lot of these. So important to keep these in mind when you're getting a patient's history. Hip dislocation or fracture, femoral neck stress fracture, things like sickle cell disease, pediatric hip problems, steroid use, alcohol use, tobacco use, their scuba diver, have they had the bends? And then you may not have those risk factors, but just the right age group. So 40 to 65 and men more than women. So that demographic is higher risk for AVN as well. Imaging, early on x-rays may not show the pathology. MRI is generally the best imaging modality if you're concerned about AVN and someone who's high risk who has hip pain on a normal x-ray. Treatment, if they're asymptomatic or it's early on, small lesion without articular involvement, without collapse, you know, conservative management's helpful. If it's more advanced, they've got a collapse, they've got osteoarthritis, and then they may go on for surgery. If they don't have osteoarthritis, then sometimes a decompression surgery or osteotomy is done. If they've got more significant collapse or arthritis, then often they'll go on for hip arthroplasty. There is some concern about doing steroid injections in this population, but usually, when I've asked a surgeon about it, they say, go for it. If they collapse, then we'll take care of it. But in patients that have really severe pain in AVN, sometimes we don't have a whole lot else to offer if they're not ready for surgery. So this is what you're gonna look for on x-ray. This is a crescent sign here on the left showing where that pathology is. And then here on the right, this is much more advanced where you see collapse of the femoral head. You can also see some signs of osteoarthritis forming here as well. On MRI, you see this kind of serpiginous line. In this patient here, it's got bilateral findings on the right, on the left image here, just on the one side. So that's what you'd look for on an MRI. Okay, hip dislocations. So this is not something that generally we manage, but some of us do sports coverage, so it's important to be aware of this and know how it presents. So most common hip dislocation is posterior, and that's a posteriorly directed force to a flexed hip and knee. And the patients present with the hip flexed, adducted, and internally rotated, so in that fade air position, can't bear weight. Less common is an anterior hip dislocation, and that's an axial directed force with the hip and the knee extended. And that presents with the hip flexed, abducted, and actually rotated to the favor position. Ortho manages this, so I'm not gonna talk much about management. All right, so that's it for intraarticular. I'm gonna move on to talk about a little bit of extraarticular. Again, the items here that are in bold are the things that I'm going to talk about more. Note, I am not talking about core muscle injury today. That's just a huge topic that needs almost a whole lecture on its own. Okay, so the most common injury to the hip that's extraarticular is a groin pull or adductor strain. This is more likely in the preseason when athletes are poorly conditioned. It occurs with a sudden change in direction. Of the six kind of muscles that are involved in adduction, the adductor longus is the one that's most commonly injured here. You see that one right here. And I'm pointing to our anatomy image there. Treatment for this sort of thing, generally, you know, our initial conservative management, rest, ice, compress, elevate. Want to avoid stretching as that can lead to more tendinopathy and poor healing. And then once pain is improved, then we start some progressive strengthening exercises, starting with just kind of isometrics and then progressing on from there as they're able. And we always wanna make sure we're addressing other factors as well. Are there, is there tightness in the spine or the hip? Is there core weakness? And we need to work on conditioning to try and prevent those injuries going forward. The other kind of muscle tendon group that we think about commonly at the hip is the iliopsoas. And so this can be indicated with kind of muscle strains as well. There's also a bursa deep to the iliopsoas where you can get bursitis. There's also possibility for the snapping hip where either you can worry about snapping over the iliopecteinal eminence or snapping of the iliopsoas tendons over one another. If we're talking about acute injury here, that generally happens with an explosive hip flexion or eccentric overload. On exam, they're gonna have pain with resisted iliopsoas activation and pain with adduction with the hip inflection because the iliopsoas can also act as an adductor in that position. Treatment is gonna be similar to your adductor strain. If they've got bursitis and you can think about an injection, if they've got snapping hip that's asymptomatic, we don't worry about it. And most cases of that snapping are asymptomatic. Okay, the other most common thing that we talk about with extra articular hip pain is greater trochanteric pain syndrome. So this is pain over the greater trochanter, generally pretty focal. Previously it was thought to be bursitis and was always called hip bursitis, greater trochanteric bursitis, but very few cases are actually bursitis. Most of it is an issue of shearing of the peritrochanteric soft tissues due to weakness in the hip or altered biomechanics. They often have tendinopathy of these gluteal tendons. So the anatomy here, the most superficial is our gluteus maximus that does not attach at the greater trochanter. Deep to that is the gluteus medius and then deep to that is the gluteus minimus and those do attach out there at the greater trochanter. Gluteus medius and minimus are the ones that we're generally talking about here. And you can see tendinopathy or small tears in those tendons at their insertions. This is often referred to as the rotator cuff of the hip and we see similar pathologies here that we do in the rotator cuff in the shoulder. So you can have calcifications in the tendons there as well, similar to the shoulder. This is showing anatomy image here of where those tendons attach. And so anteriorly we have gluteus minimus, laterally gluteus medius and then overlying gluteus maximus and posteriorly and the TFL anteriorly near IT band superficial. Treatment is generally conservative with physical therapy and I try and try and try to get my patients to buy into doing physical therapy to work on strengthening these muscles. Oftentimes these patients just want a steroid injection. I try to convince them that that's not going to solve their problem, especially long-term. It may give them some short-term pain relief if we do an injection of steroid into the bursa, but it's not gonna fix their issue. So generally, if they fail conservative management strengthening, maybe we talk about doing a tendon treatment. So it was something like a tenotomy where we pass a needle through the tendon to try and address tendinopathy and that can be done with injection of platelet-rich plasma or autologous blood to try and help to augment that healing response. The concern with steroid is that if you inject steroid into the tendon, then that can lead to tendon rupture. So especially if they already have a partial tear in their tendon, we don't really want to worsen that. I will just point out one other thing. There are three bursa indicated by these white lines around the greater trochanter, but the subgluteus maximus or greater trochanteric bursa, subgluteus medius and subgluteus minimus bursa. So usually when people are talking about greater trochanteric bursitis, they're talking about this subgluteus maximus bursa here. All right. A couple of other things to talk about briefly. Osteitis pubis. So you can see it here on the X-ray. This pubic symphysis looks very irregular. So this is a periosteitis or stress injury from repetitive use or avulsion. They generally have pretty focal pain to the pubic symphysis. On exam, they'll be tender there. X-ray shows these bony erosions. You have some sclerotic margins, subchondral cysts and widening. Imaging, bone scan can be helpful. CT, MRI can show marrow edema. Or treatment is usually to try conservative management first. So rest and treating underlying contributing factors. Do they need to work on their adductors? Do they need to work on these other muscles around there? There's some overlap here with the core muscle injury. I'm not going to get into that. Sometimes you can do a corticosteroid injection into the pubic symphysis to calm it down if it's really inflamed. And surgery can be done to help. And surgery can be done for refractory cases. And in these more significant cases, their return to player activity can be prolonged often nine to 10 months. So pretty significant. Another stress fracture to keep in mind is the inferior pubic ramus. You don't want to confuse this with an adductor tendinopathy. You're going to have pretty localized tenderness, but it's not going to be worsened by stressing their adductor. So passive abduction or resistant adduction. Pain often refers to the buttock. And imaging, again, as it was for the femoral stress fracture, bone scan or MRI is really going to be helpful. X-rays often aren't going to show this. Treatment, you want to address any risk factors for things like female athlete triad and red S. So getting a history of their diet, menstrual history, history of other stress fractures to address those contributors if needed. They're going to rest until the tenderness resolves and then gradual return to weight bearing and then running. So less risk than that femoral stress fracture. And then this is in our adolescent population. They get these avulsion or hypothesial injuries. And this usually is an acute injury that occurs from a strong eccentric load. Muscle attachments around the pelvis, they'll get an avulsion of bone away from, with the tendon rather than the tendon tearing. X-rays can diagnose this. And you also want to do an X-ray to see how displaced the bony fragment is. Because if it's more than two centimeters, often they're going to go for surgical repair. If it's less than that, then usually it's just protected weight bearing until they're pain-free. Avoid stretching early on to allow that to heal. And then gradual rehab back to their sport once they're feeling pain-free. This shows these most common sites for these avulsion injuries. And this is something that's very testable. It's also important to know these attachment sites. So the iliac crest is your abdominal muscles. And so you'd be looking for that on an X-ray. The ASIS for the sartorius, TFL. AIIS for the rectus femoris. The pubic ramus for your adductors. And gracilis. And schial tuberosity for the hamstrings. Lesser trochanter for the iliopsoas. And the greater trochanter for those gluteal muscles. All right, just a few little summary points here. Always be aware that there can be overlap from both intraarticular and extraarticular sources of pain. It's important to perform a thorough history exam and work up with appropriate imaging studies. If X-rays are negative and your concern is high, get an MRI. Don't feel like you need to send someone to therapy first, even though insurance always wants that. If they're in significant pain, an MRI is gonna show those really risky issues like AVN or a stress fracture that can really change your management. And then diagnostic injections into the hip joint can play an important role to determine if pain is coming from an intraarticular source. All right. Thank you all. I am happy to answer any questions now or by email for follow-up later. Thank you very much. This was a great kind of tour of some of these injuries that athletes can have. Couple of questions. I think if anybody has any questions, feel free to send them in. But I'm gonna start with a couple of questions. One, for greater trochanteric pain syndrome, if there's a tendinosis component to this, is there any evidence for like tendon scraping, focused ultrasound or any other? I know you mentioned tenotomy. Are there any other kind of interventional options here or is it mostly just focused around like rehab? Yeah. So, I mean, definitely rehab is the number one thing in trying to work on strengthening and addressing any of those biomechanical issues. Aside from doing tenotomy, other sort of interventions that can be considered for tendon issues. I don't know how much this is done at the hip, but you could consider something like shockwave. But again, that's something that insurance doesn't cover. But really the main treatment is gonna be strengthening exercises. Okay. Thanks. In terms of initial approach to imaging, I know depending on what you're concerned about, you might have a different modality to choose from. So for FAI syndrome, I know x-ray would be appropriate. Peripheral neck stress fracture may be only seen on CT, but for AVN, MRI. So when you're approaching this, somebody comes in and has kind of these symptoms that don't really pinpoint it. Where do you, how do you approach that in terms of imaging? Yeah. So usually I'm getting imaging if I'm thinking someone's got an intraarticular source of pain. Because otherwise, or if they had an acute injury, a trauma. And generally we're always starting with x-ray. And x-ray is always going to be two views, the AP pelvis and a lateral view of the affected hip. Unless for some reason, you know, if it's someone who's maybe a young female and I'm really concerned that they've got a stress fracture, I might jump to the MRI to try and save some radiation exposure. But otherwise, if we're thinking that they've got something like a hip impingement, FAI syndrome or other, or osteoarthritis, we're going to start with an x-ray. If that's negative, and it's, like I said, it's someone with, you're really concerned about, either they've got severe pain, they can hardly walk, then I'm generally jumping to an MRI. And the reasons there is it can show a lot of things and doesn't have associated radiation exposure. So it can show all of the really high risk things like fractures, AVN, transient osteoporosis of the hip, which I didn't talk about, all of those things that would really alter your management. So if an x-ray doesn't get you to where you have a good answer, then usually it's MRI. Rarely am I doing a CT or a bone scan. Okay. Is there a time, I'm getting a question now, is there a time that you might go to ultrasound for a diagnosis? Yeah. So ultrasound can really be helpful for things like greater trochanteric pain syndrome. If you want to look for a tendinopathy, it can be really helpful for a snapping hip, looking at those iliopsoas tendon over the hip, because you can also do a dynamic portion of the exam. And there have been some studies suggesting that it's really helpful for CAM morphology as well, but that hasn't, I don't think been studied enough yet to say that that is a diagnostic imaging modality of choice for looking at the CAM morphology, but there definitely are some indications. If you're worried that someone's got like a synovitis or inflammatory issue with the hip, ultrasound is great at looking for fluid in the hip capsule. So there's definitely some times when ultrasound really is helpful, mostly if we're thinking about something with tendons, you want a dynamic exam, like a snapping hip, which I didn't talk about too much, or if you want to look at the hip capsule specifically. Okay, I appreciate it. I think that snapping hip, the dynamic piece of that is really interesting. If anybody wants to see a dynamic exam with a classic snapping hip, I think Steve Schaaf posted an exam on Twitter. So if you want to track him down, S-C-H-A-A-F, his Twitter account, has a video of a dynamic ultrasound exam of a snapping hip. I thought that was interesting. Okay, I think, so somebody asked if ultrasound is used to guide the injections. I think specifically the injections on the hip. Yeah, so for most of my hip injections that I'm doing, I use ultrasound, which is quite reliable. I'm very confident that I'm getting my injection where I want it to go for an intra-articular injection. If I'm doing a greater trochanteric injection, I'm always using ultrasound for that generally. The times that I'll use fluoroscopy for an intra-articular hip injection is either due to patient factors. So a BMI that's really high and I just can't get the penetration that I need to in the ultrasound to see down to their hip joint. Or if you've got somebody with like a hip flexion contracture, like I have a patient who I've injected their hip for hip OA with hip dysplasia and the setting of brain injury and spinal cord injury, he's got a hip flexion contracture. And so I can't get the approach that I need to ultrasound. So I do that one with a lateral approach under fluoroscopy. Or if I wanna be really confident that I'm doing an intra-articular injection, use of contrast dye with fluoroscopy gives you that confidence. While I'm pretty certain with ultrasound, I can't tell a surgeon 100%, you know, this was in the joint, but I can show them a fluoro image with contrast in the joint and say, yes, this was on intra-articular. So a few times that I might use fluoro instead of ultrasound. Okay. Thank you very much. That's helpful. I pulled up, see if I can find it here. Yep. I pulled up the video of the snapping hip exam. That was interesting and relevant. Again, thank you so much for joining us. I appreciate it. If anybody has any further questions, feel free to send them to me or again, that email address I believe is up and I think we have it here. Yes. So thank you all for joining us. Dr. Loveless, thank you so much. This was a great lecture and we appreciate it. If anybody has any further questions, feel free to reach out to her there at that email address. Is that correct? Yes, thank you. Excellent. Or you can track us down on Twitter. Again, thank you for joining us. We appreciate you spending time with us today and for everybody who was participating today, we look forward to having you tomorrow. Thank you again.

hip pain

intraarticular hip problems

groin pain

lumbar sources

anatomy of the hip joint

femoroacetabular impingement (FAI) syndrome

hip osteoarthritis

labral tears

MRI