The Basics  Friday, October 14, 2011 • 16:15 – 17:35pm 

Room A 

Traction   Allston Stubbs, MD USA 

 

Supine Approach Jonathan Baré, FRACS AUSTRALIA 

 

Lateral Approach Joseph McCarthy, MD USA 

 

Portals and PeriPortal Anatomy Nick Mohtadi, MD CANADA 

 

Central/Peripheral Compartment Anatomy   Michael Dienst, MD GERMANY 

 

Physical Exam of the Hip   Hal Martin, DO USA 

 

Radiographs  Kevin Willits, MD, FRCSC CANADA 

 

CT   Robert Buly, MD, MS USA 

 

MRI   Miriam Bredella, MD USA 

 

Ultrasound   Carlos Guanche, MD USA 

   

Lecture: Traction Allston J. Stubbs, MD 

 

 

Lecture: Supine Approach Jonathan Victor Baré, FRACS 

 

 

Lecture: Lateral Approach Joseph C. McCarthy, MD 

 

 

Lecture: Portals and PeriPortal Anatomy Nick  Mohtadi, MD 

 

 

Lecture: Central/Peripheral Compartment Anatomy Michael  Dienst, MD 

 

 

ISHA Annual Scientific Meeting

The Physical Examination of the Hip

Hal David Martin, DO

Oklahoma Sports Science and Orthopaedics

The Hip Clinic

Oklahoma City, OK

Evolution of the Hip Physical Examination

Goals

History

The Pattern and Technique in the Clinical Evaluation of the Adult Hip: The Common

Physical Examination Tests of Hip Specialists

Reliability of Clinical Diagnosis

4 Layer Diagnosis. Osseous, Capsulolabral, Musculotendinous, and Neurovascular.

Standardization of Physical Examination

Standing Examination

Seated Examination

Supine Examination

Lateral Examination

Prone Examination

Specific Tests

Radiographic and Diagnostic Testing

References

1. Byrd JWT. Physical Examination. In: Byrd JWT (ed), Operative Hip

Arthroscopy. New York: Springer:36-50,2005.

2. Clohisy JC, Keeney JA, Schoenecker PL. Preliminary assessment and treatment

guidelines for hip disorders in young adults. Clin Orthop Relat Res 441:168-179, 2005.

3. Clohisy JC, Knaus ER, Hunt DM, Lesher JM, Harris-Hayes M, Prather H.

Clinical presentation of patients with symptomatic anterior hip impingement. Clin Orthop

Relat Res 467:638-644, 2009.

4. Ganz R, Parvizi J, Beck M, Leunig M, Notzli H, Siebenrock KA.

Femoroacetabular impingement: a cause for osteoarthritis of the hip. Clin Orthop Relat

Res:112-120, 2003.

5. Hoppenfeld S, Hutton R. Physical examination of the hip and pelvis. In:

Hoppenfeld S, Hutton R (eds), Physical examination of the spine and extremities. Upper

Saddle River: Prentice hall:143-169,1976.

6. Martin HD. Clinical Examination of the Hip. Operative Techniques in

Orthopaedics 15:177-181, 2005.

7. McCarthy JC, Busconi BD, Owens BD. Assessment of the painful hip. In:

McCarthy JC (ed), Early Hip Disorders. New York, NY: Springer:3 - 6,2003.

8. Ober F. The role of the ilio-tibial band and fascia lata as a factor in the causation

of low-back disabilities and sciatica. J Bone Joint Surg Am 18:105-110, 1936.

9. Reider B, Martel J. Pelvis, hip and thigh. In: Reider B, Martel J (eds), The

orthopedic physical examination. Philadelphia: WB Saunders:159-199,1999.

10. Martin HD, Shears SA, Palmer IJ. Evaluation of the hip. Sports Med Arthrosc

18:63-75, 2010.

11. Beaule PE, Zaragoza E, Motamedi K, Copelan N, Dorey FJ. Three-dimensional

computed tomography of the hip in the assessment of femoroacetabular impingement. J

Orthop Res 23:1286-1292, 2005.

12. Beck M, Leunig M, Parvizi J, Boutier V, Wyss D, Ganz R. Anterior

femoroacetabular impingement: part II. Midterm results of surgical treatment. Clin

Orthop Relat Res:67-73, 2004.

13. Burnett RS, Della Rocca GJ, Prather H, Curry M, Maloney WJ, Clohisy JC.

Clinical presentation of patients with tears of the acetabular labrum. J Bone Joint Surg

Am 88:1448-1457, 2006.

14. Byrd JW, Jones KS. Diagnostic accuracy of clinical assessment, magnetic

resonance imaging, magnetic resonance arthrography, and intra-articular injection in hip

arthroscopy patients. Am J Sports Med 32:1668-1674, 2004.

15. Ito K, Leunig M, Ganz R. Histopathologic features of the acetabular labrum in

femoroacetabular impingement. Clin Orthop Relat Res:262-271, 2004.

16. Kassarjian A, Yoon LS, Belzile E, Connolly SA, Millis MB, Palmer WE. Triad of

MR arthrographic findings in patients with cam-type femoroacetabular impingement.

Radiology 236:588-592, 2005.

17. Keeney JA, Peelle MW, Jackson J, Rubin D, Maloney WJ, Clohisy JC. Magnetic

resonance arthrography versus arthroscopy in the evaluation of articular hip pathology.

Clin Orthop Relat Res:163-169, 2004.

18. Klaue K, Durnin CW, Ganz R. The acetabular rim syndrome. A clinical

presentation of dysplasia of the hip. J Bone Joint Surg Br 73:423-429, 1991.

19. Leunig M, Werlen S, Ungersbock A, Ito K, Ganz R. Evaluation of the acetabular

labrum by MR arthrography. J Bone Joint Surg Br 79:230-234, 1997.

20. Macdonald S, Garbuz D, Ganz R. Clinical evaluation of the symptomatic young

adult hip. Semin Arthroplasy 8:3-9, 1997.

21. Martin HD, Kelly BT, Leunig M, et al. The pattern and technique in the clinical

evaluation of the adult hip: the common physical examination tests of hip specialists.

Arthroscopy 26:161-172, 2010.

22. Philippon MJ. The role of arthroscopic thermal capsulorrhaphy in the hip. Clin

Sports Med 20:817-829, 2001.

23. Fitzgerald RH, Jr. Acetabular labrum tears. Diagnosis and treatment. Clin Orthop

Relat Res:60-68, 1995.

24. Bharam S. Labral tears, extra-articular injuries, and hip arthroscopy in the athlete.

Clin Sports Med 25:279-292, ix, 2006.

25. Braly BA, Beall DP, Martin HD. Clinical examination of the athletic hip. Clin

Sports Med 25:199-210, vii, 2006.

26. Philippon MJ, Schenker ML. Arthroscopy for the treatment of femoroacetabular

impingement in the athlete. Clin Sports Med 25:299-308, ix, 2006.

27. Philippon MJ, Stubbs AJ, Schenker ML, Maxwell RB, Ganz R, Leunig M.

Arthroscopic management of femoroacetabular impingement: osteoplasty technique and

literature review. Am J Sports Med 35:1571-1580, 2007.

28. Martin RL, Sekiya JK. The interrater reliability of 4 clinical tests used to assess

individuals with musculoskeletal hip pain. J Orthop Sports Phys Ther 38:71-77, 2008.

Lecture: Radiographs Kevin  Willits, MD, FRCSC 

 

 

Lecture: CT Robert Leon Buly, MD, MS 

 

 

MRI

Miriam A. Bredella, MD

Massachusetts General Hospital and Harvard

Medical School

Boston, MA

ISHA Annual Meeting 2011

Hip MRI

• Intra-articular

– labrum

– cartilage

– lig. teres, capsule

• Extra-articular

– tendons, muscles

– bursa

• Osseous

– stress fracture

Intra-articular pathology

MR arthrography

• contrast material

• distends capsule

• outlines structures

• fills labral tears

• cartilage delamination

Oblique axial plane

• FAI: concavity

femoral head-neck

junction, alpha angle

37º

Alpha angle

Nl. < 55 °

79º

Abnormal head-neck junction

Nl. < 55 °

Cartilage

• Intermediate SI

– thick superior, thin

posterior

• Sports-related, cam FAI:

ant-sup acetabulum

– delamination

• Pincer FAI: post-inf

Labrum

• Fibrocartilage (SI)

– thick posterior, thin anterior

• Triangular on all planes

• Sports-related, cam FAI: ant-sup

• Pincer FAI: post-inf

• Paralabral cyst

• Arises from acetabular fossa

• Inserts into fovea capitis

• Blends in with transverese lig.

• Low SI

• 4-15% of sport related injuries

• Partial, complete tears,

avulsions

Lig. teres

• Gluteals

• Iliopsoas

• Hamstrings

• Rectus femoris

• Quadratus femoris: ischiofemoral

impingement

Tendons and muscles

• Gluteus medius, minimus

– rotator cuff of hip

• gluteus medius: sup.-post.

facet, lateral facet

• gluteus minimus: anterior

facet

• Greater trochanteric pain

syndrome

Gluteal tendons

Pfirrmann CW et al, Radiology 2001;221:469-77

• Repetitive trauma

• Snapping hip

– iliopsoas tendon

snapping over

iliopectineal line

• Inflammatory

conditions (RA)

Iliopsoas bursitis

• Narrowing of ischiofemoral

space

– ischial tuberosity and lesser

trochanter

• Quadratus femoris muscle

– edema, partial tear, fatty

infiltration

• Hamstring tendons

– edema, partial tear

Torriani et al. AJR 2009;193:186-90

Ischiofemoral impingement

Stress fracture

• Nl bone, increased activity

• Propensity for extension

• Inf-med fem neck

• T1: geographic

• T2, STIR: fx line

• Joint effusion, ST edema

Checklist:

• IA pathology (labrum, cartilage), capsular injuries

→ MR arthrography

• Evaluate lig. teres

• Tendons:

– Rotator cuff of hip: anatomy of gluteus insertions

– Iliopsoas tear: check lesser trochanter for mass

– Rectus femoris: straight, reflected head

– Ischiofemoral impingement

• Stress fx

Hip Ultrasound

Carlos A. Guanche, MDSouthern California Orthopedic Institute

www.scoi.com

Hip Imaging

• Ultrasound– Introduced in 1978 for eval of DDH– Historically: Operator dependent– Cost Prohibitive for Office– Established in Pediatrics

• Useful in confirming subluxation• Identifying dysplasia of cartilaginous acetabulum• Documenting reducibility

– Availability of MRI has limited use in US

Ultrasound

Femoral head

Abductors

Ilium

Hip Ultrasound:Advantages

• Images:– Muscle– Tendon– Soft tissues– Bone surfaces

• Dynamic “live” exam• Portable and relatively inexpensive• High resolution without radiation• Images not degraded by implants• Bilateral Comparison easy• No side-effects

Hip Ultrasound:Disadvantages

• Operator and hardwaredependent

• Limited resolution below 9 cm• Can’t image through bone• No scout image• Clinician learning curve

Reasons to Use Ultrasound

• Office convenience– Diagnostic (vs MRI?)

• Quick cuff assessment

• TSR vs Reverse

– Diagnostic Injection -Guaranteed!

• Financial Benefits

Financial AnalysisDIAGNOSTIC

INJECTION

% of MC How does it work?

Physics of Ultrasound

• Snell’s Law:

• Reflection coefficient:

• Transmission coefficient:

Ultrasound Transducer

Speakertransmits sound pulses

Microphonereceives echoes

• Acts as both speaker & microphone– Emits very short sound pulse– Listens a very long time for returning echoes

• Can only do one at a time

US TransducerOperation

• alternating voltage (AC) appliedto piezoelectric element

• Causes– alternating dimensional changes– alternating pressure changes

• pressure propagates as soundwave

What does your scannerknow about echoed sound?

How loud is the echo?

♦inferred from intensity of electrical pulse from transducer

What does your scanner knowabout echoed sound?

What was the time delaybetween sound broadcast

and the echo?

What does your scanner knowabout echoed sound?

The sound’s pitch orfrequency

Ultrasound Display

• B-scan (“Brightness” Mode)Image– series of gray shade dots

• For each dot, scannermust calculate– position– Gray shade

Dot Placement on Image

• Dot position ideallyindicates source ofecho

• scanner has no way ofknowing exactlocation– Infers location from

echo

?

Dot Placement on Image

• Dot positioned along assumed line• Calculated based upon

– speed of sound– time delay between sound transmission &

echo

?

Gray Shade of Echo

• Ultrasound is gray shademodality

• Gray shade should indicateechogeneity of object

? ?

How does scanner know whatgray shade to assign an echo?

• Based upon intensity (volume,loudness) of echo

? ?

Gray Shade

• Loud echo = bright dot• Soft echo = dim dot

Ultrasound Display

• One sound pulseproduces– one image scan line– one series of gray

shade dots in a line

• Multiple pulses– two dimensional image

obtained by movingdirection in whichsound transmitted

Clinical ApplicationsAnatomy

Ultrasound AnatomyASIS SARTORIUS

DISTALPROXIMAL

Ultrasound Anatomy

DISTALPROXIMAL

AIIS RECTUS

Ultrasound Anatomy

AC FH

ANT CAPSULEPSOAS

DISTALPROXIMAL

Hip (Intraarticular) Injection

Supine PositionProbe Longitudinal

Psoas Sheath Injection

FH

Psoas Muscle Psoas Tendon

FA

Supine PositionProbe Transverse

Left Hip

Psoas Sheath InjectionLeft Hip

Medial Lateral

Right Hip

Medial Lateral

Snapping (External) Hip

Lateral PositionProbe Transverse

GT

POSTERIOR ANTERIOR

Snapping (External) HipTrochanteric Bursitis &

Abductor Tears

GT GT

*

Gluteus MediusTear

ITB

Abductor Tears

GT GT

*

GT

Abductor Tears

Summary

• Diagnostic Ultrasound is technicallyfeasible– Convenience– Financially efficacious

• Operator Dependent– Courses Available– Practice until comfortable with

anatomy

Thank You!