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​

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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​

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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​

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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​

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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​

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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​

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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​

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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​

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- 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​

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- 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​

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