Paediatric Young Adult Orthopaedic Information

By Sheila on about misc

Causes of hip pain

Bony abnormalities

  1. Femoroacetabular impingement

    Femoroacetabular impingement or FAI is a condition in which the femoral head (ball), acetabulum (socket), or both are shaped abnormally and so do not fit perfectly, causing friction during hip movements, resulting in damage within the hip joint. The damage can occur to the articular cartilage (smooth white lining of the ball or socket) or the labral cartilage (soft tissue bumper that surrounds the socket).

    Impingement can occur from the femoral side (known as cam impingement), from the rim of the acetabulum (known as pincer impingement), or a combination of both.

    1. Cam impingement
      During motions such as hyperflexion and internal rotation of the hip, the abnormally shaped ball is unable to fully engage within the joint, resulting in cartilage (lining) loss over the ball and corresponding socket, as well as labral tears. Once lining is lost, this becomes a pre-arthritic condition.
    2. Pincer impingement
      In the pincer-type lesion, there is "over coverage" of the socket (acetabulum) in respect to the ball (femoral head). This extra bone of the acetabulum repetitively hits upon the femoral neck resulting in the pinching of the labrum in between.
    3. Combined
      Cam lesions may coexist with pincer lesions. Cam lesions lead to articular cartilage (lining) injury first, whereas pincer lesions crush and tear the labrum first.

Investigations

  1. X-rays

    An X-ray is a 2 dimensional view of a bone(s). Patients will often show up the day of their appointment without their X-rays as they were deemed to be normal. However, this is not always the case and so, please bring all your previous imaging to your appointment in Australia.

    Mr Ramachandran will obtain some or all of these following X-ray views:

  2. MRI/MRA

    Although the gold standard for diagnosing a labral tear is an MR arthrogram (where an MRI scan is taken after dye is injected into the hip joint under sterile conditions), sometimes adequate information to proceed to surgical intervention is available from a plain MRI scan. These studies look at all the soft tissue, including labral tears, muscular tears, ligament tears, cartilage defects and arthritis.

  3. CT scan

    A CT scan may be ordered to obtain more information about bony anatomy.

Non-operative treatment

  1. Physiotherapy

    Physiotherapy is aimed at strengthening the hip muscles, increasing flexibility, maintaining the range of motion of the hip joint, and decreasing the inflammation associated with injury or surgery.

    Although physiotherapy cannot in itself heal labral or cartilage tears, it is possible for a tear to become asymptomatic with appropriate muscular training and activity modification and therefore not require surgery.

    Pre-surgery physiotherapy is very important for those patients who present with extreme weakness or stiffness.

  2. Anti-inflammatories

    Anti-inflammatories are used primarily to treat mild to moderate pain associated with inflammation. Inflammation is associated with muscular tears, bursitis, tendonitis, arthritis, labral tears, and synovitis. Anti inflammatories are used as a first line treatment in conjunction with a strengthening program and are also used post-operatively if required.

    Long-term use is discouraged because of the risk of side-effects, especially on the stomach and kidneys.

Stage I – Protected weight bearing
This should be followed whilst the patient is using walking aids, and may last 2 – 6 weeks depending on the level of surgical intervention. These exercises are aimed at restoring range of movement and maintaining muscle function whilst allowing tissue healing and pain to settle.

Stage II – Intermediate exercises
Once fully weight bearing and experiencing minimal levels of discomfort, these exercises e.g. squats and step-ups may be commenced with the guidance of the physiotherapists. Ideally range of movement in the involved hip should be at least 80% of the uninvolved side. Exercises taught in this stage are aimed at restoring and maintaining movement, promoting normal walking patterns, strengthening muscle and improving balance reactions. There is a strong focus on core stability work at this stage.

Stage III – Advanced exercises
These exercises e.g. lunges should only be commenced when range of movement is full, walking is normal and pain free and muscle strength is greater than 70% of the uninvolved side in all directions. The goals of this stage are the restoration of muscular and cardiovascular endurance, and the improvement of balance reactions. Return to social sport should be possible at this stage.

Stage IV – Sports specific training
Not all patients require rehabilitation to this level. Those who take part in competitive sport will certainly benefit from further strengthening and more sports specific exercise. Training regimes for this stage should be developed in conjunction with sports club physiotherapists or personal trainers.