Trochanteric Bursitis/Syndrome

  • Cause/Pathophysiology

    • Bursitis - Overuse use/pressure on greater trochanter, inflammation of only the bursa 

    • Syndrome - may result from inflammation of the bursa, gluteus tendons, IT band, fascia

      • Also may be related to chronic gluteus ten​denopathy

  • History and symptoms

    • Complaints of lateral or posterolateral hip pain

    • Pain with side-lying

    • +/- pain at rest

  • Exam Findings

    • TTP over greater trochanter

    • Usually pain-free ROM

    • Tight ITB - + Ober

  • Imaging

    • Clinical diagnosis

    • X-Ray can rule out other hip pathology

  • Treatment​

    • NSAIDs

    • PT

    • Cortisone injection

  • Common ICD-10 codes

    • M70.60

Osteoarthritis

  • Cause/Pathophysiology

    • Chronic degeneration of femora-acetabular articular cartilage

  • History and symptoms

    • Gradually worsening pain usually in the anterior groin and thigh

    • Worse with WB

    • Eventually causes pain at rest

  • Exam Findings

    • Decreased ROM 

    • Pain with PROM, especially IR/ER

    • + Stinchfield sign

  • Imaging

    • X-Ray - decreased joint space, osteophytosis, possible femoral head deformity

  • Treatment​

    • First line

      • NSAIDs​

      • PT - limited benefit

    • Second line

      • Ultrasound or fluoroscopic guided Intra-articular cortisone injection​

    • Surgery - Total hip arthroplasty​

  • Common ICD-10 codes

    • M16.10

Femoro-acetabular Impingement (FAI)

  • Cause/Pathophysiology

    • Anatomic abnormalities result in mechanical impinging of the femoral heal and acetabular rim

    • Commonly associated with labral tear

  • History and symptoms

    • Vague anterior, lateral, or posterior hip pain with activity or at rest

  • Exam Findings

    • +/- decreased ROM

    • +/- pain with end-range motion

    • +/- Faber test 

  • Imaging

    • X-Ray  

      • +/- CAM deformity of femoral head - superior head is elongated

      • +/- Pincer lesion - "spurring" of the superior acetabulum

  • Treatment​

    • First line

      • NSAIDs​

      • PT

    • Second line

      • Surgery vs IA cortisone injection​​

        • Depends on age and activity level of the patient.  I typically lean more to surgical referral for younger patients.​
  • Common ICD-10 codes​​​
    • M25.859​

Labral Tear

  • Cause/Pathophysiology

    • Usually degenerative tearing of the acetabular labrum, frequently associated with FAI

    • Usually younger patients, teens to 30-40's

  • History and symptoms

    • Vague pain usually anterior/lateral

    • +/- pain with activity and rest

    • +/- mechanical symptoms

  • Exam Findings

    • +/- "C" sign 

    • +/- pain with end-range ROM

    • +/- Stnichfield sign

    • +/- Faber test

  • Imaging

    • X-Rays may show signs of FAI (CAM femoral head deformity or acetabular pincer lesion)

    • CT arthrogram

  • Treatment​

    • First line

      • NSAIDs​

      • PT

    • Second line

      • Surgery (arthroscopic repair) vs IA cortisone injection​

        • Depends on age and activity level of the patient.  I typically lean more to surgical referral for younger patients.​

  • Common ICD-10 codes​​​

    • M25.859

 

Synovitis

  • Cause/Pathophysiology

    • Aseptic - inflammatory process of the hip synovium usually associated with a viral infection

    • Septic/Toxic - bacterial infection of the joint.  Can result from recent illness.

    • Usually pediatric population

  • History and symptoms

    • Complaint of Pain

    • Parent observes abnormal/antalgic gait 

    • Frequently a history of recent illness

  • Exam Findings

    • Aseptic 

      • non-toxic appearance

      • afebrile usually

      • decreased ROM due to pain and guarding

    • Septic

      • toxic appearance​

      • febrile

      • decreased ROM due to pain and guarding

  • Imaging 

    • X-Rays - negative

    • Frequently treatment is based on clinical picture.  If aseptic appearing, no further imaging is immediately necessary

    • Ultrasound with aspiration if septic synovitis is suspected

  • Treatment​

    • Aspetic​ - Usually resolves with conservative treatment within a week or so

      • NSAIDs​

      • Non-weightbearing on extremity

      • rest

      • MONITOR VERY CLOSELY FOR WORSENING OF CONDITION.  CALL OR FOLLOW-UP IN A COUPLE OF DAYS. 

    • Septic - EMERGENT REFERRAL FOR ULTRASOUND/ASPIRATION and SURGICAL IRRIGATION IF SEPTIC JOINT IS CONFIRMED

  • Common ICD-10 codes

    • M67.359

Avascular Necrosis

  • Cause/Pathophysiology

    • Vascular disruption to the femoral head causes bone death and eventual femoral head collapse

    • Unknown exact mechanism, but can have association with increased lipids, ETOH, steroid use, trauma, sickle cell

  • History and symptoms

    • Usually under 50

    • Pain in groin, thigh, or buttock

    • Worse with weight bearing

  • Exam Findings

    • Antalgic gait

    • +/- Decreased ROM

    • Painful PROM, especially IR/ER

    • Pain may be out of proportion

  • Imaging

    • X-Ray - flattening/collapse of femoral head

      • If very, early there may be no obvious changes​

    • MRI - Order if X-Rays are negative and there is a high clinical suspicion

  • Treatment​

    • Surgical 

      • If not collapse, may be candidate for core decompression of Free Fibular grafting​

      • If collapse, total hip arthroplasty

  • Common ICD-10 codes​​

    • M87.059

Strain

  • Cause/Pathophysiology

    • Acute muscle injury, usually from an excessive sudden concentric contraction or excessive eccentric load greater than the concentric muscle contraction

    • Tearing of muscle fibers

    • Most frequently the quadriceps or hamstring muscle groups

    • Grading can be based on physical exam findings or dysfunction 

  • History and symptoms

    • Sudden onset of pain, usually occurs during running

    • Pain worse with movement

  • Exam Findings

    • +/- antalgic gait depending on severity

    • +-/- swelling, deformity (divot) in muscle, ecchymosis

    • Pain with strength testing,

    • +/- weakness

    • Limited ROM

  • Imaging

    • If symptoms are near origin or insertion, X-Rays to evaluate for avulsion injury 

  • Treatment​

    • RICE

    • +/- crutches depending on severity

    • PT

    • +/- NSAIDs

  • Common ICD-10 codes

    • S72.109A

Common Fractures (You will not see these often in the outpatient clinical setting, but important to know)

- Femoral neck

  • Cause/Pathophysiology

    • Trauma/fall

    • Fracture anywhere from the base of the femoral head to the trochanter

    • Usually elderly

    • Osteoporosis is a big risk factor

  • History and symptoms

    • MOI

    • Pain in hip or thigh

    • May or may not be able to bear weight

  • Exam Findings

    • +/- limb deformity (usually shortening or rotational)

    • Pain with PROM

  • Imaging

    • X-Ray

    • CT or MRI, if X-Ray negative with strong clinical suspicion (MRI is more sensitive and a better study to use in this scenario)

  • Treatment​

    • Surgery

      • Percutaneous screw fixation is not displaced or impacted​

      • Hemiarthroplasty/Total hip arthroplasty if displaced​

  • Common ICD-10 codes​​

    • S72.009A

- Intertrochanteric/Subtrochanteric

  • Cause/Pathophysiology

    • Trauma/Fall

    • Fracture anywhere from base of the femoral neck to below lesser trochanter

    • Usually elderly

    • Osteoporosis is big risk factor

  • History and symptoms

    • MOI

    • Hip, thigh, buttock pain

    • Inability to bear weight

  • Exam Findings

    • Usually shortening and or rotational deformity

    • Pain with PROM

  • Imaging

    • X-Ray

    • CT may me beneficial in some cases for surgical planning

  • Treatment​

    • Surgery

      • Trochanteric Femoral Nail (TFN)​

  • Common ICD-10 codes​​

    • S72.143A

- Pubic rami

  • Cause/Pathophysiology

    • Trauma/Fall

    • Usually elderly

  • History and symptoms

    • MOI

    • Pelvic, groin, hip, or buttock pain

    • +/- able to bear weight

  • Exam Findings

    • +/- TTP over ischium or pubic symphysis

    • +/- pain with hip ROM

    • +/- with muscle strength testing

  • Imaging

    • X-Ray  - usually all that is necessary

    • CT - if concern for extension into acetabulum

  • Treatment​

    • Conservative

      • protected WB with walker or other assertive device progressing as pain allows​

  • Common ICD-10 codes​​

    • S32.509A