Degeneration of the hip joint can be accelerated with resultant hip OA if a patient has had a tear of the labrum, has femoroacetabular impingement (FAI), or has developmental dysplasia of the hip (DDH). There are numerous causes of labral tears, and currently FAI is one of the most frequently cited reasons for a labral tear. Historically a labral tear was linked to a high-impact activity such as during a sporting event like water skiing or soccer, but recent evidence has pointed toward low- level loading over time, as can be the case with FAI, which leads to degeneration of this fibrocartilaginous structure (K. Enseki et al., 2014). The location of symptoms is similar to those of hip OA, with pain concentrated in the anterior thigh and groin region. There can be episodes of clicking, catching, or locking of the joint. These symptoms occur more frequently when the labrum is torn compared to reports of these occurrences during the history from a patient with hip OA. Frequently this condition is misdiagnosed and there can be a delay in an ultimate diagnosis and appropriate treatment. During the physical examination there is no single test for the hip joint that would rule in a labral tear definitively, and often intra-articular hip pain is treated without definitively confirming the anatomical source of symptoms (K. Enseki et al., 2014). Femoroacetabular impingement occurs when there is an anatomical variation of the femoral head-neck junction and/or acetabulum resulting in premature contact at end ranges of hip motion (Reiman, Goode, Cook, Holmich, & Thorborg, 2015). This can lead to partial tears or complete detachment of the acetabular labrum, cyst formation in the bone of the acetabulum, and early degenerative OA of the hip joint (Cibulka et al., 2009). However, if diagnosed early the condition is amenable Common extra-articular hip conditions Historically patients with lateral hip pain were diagnosed with trochanteric bursitis and treated with corticosteroid injections, anti-inflammatory medications, and PT. However, it is now evident that additional pathologies, such as hip abductor tendinopathy and external coxa saltans (snapping hip), can be present and influence the progression of this condition of greater trochanteric pain syndrome (GTPS; (Redmond, Chen, & Domb, 2016). A key element of the PT examination and subsequent evaluation is the determination of the relative contributions of trochanteric bursitis, hip abductor syndrome, and external coxa saltans. With trochanteric bursitis one or more of the major or minor bursae surrounding the lateral hip, along with soft tissues inserting into the greater trochanter region, can be affected (Fearon et al., 2013). Although bursitis may become chronically painful, it cannot be treated with THA and often becomes worse in patients who must undergo THA surgery. Like a gluteus medius tear, bursitis pain is usually located at the lateral hip; this is in contrast to hip OA, which tends to refer pain into the groin and inner thigh. In addition to the different location of the pain, the authors of a study in 2012 found that individuals with greater trochanteric bursitis did not have difficulty with putting on socks and shoes whereas those with hip OA did (Fearon et al., 2013). Patients with bursitis typically respond
to conservative treatment consisting of nonsteroidal anti- inflammatory medications and activity modification to reduce compression and end-range movements of the joint. Chronic, symptomatic cases of FAI may require debridement of bone spurs at the joint via arthroscopy or a minimally invasive open incision. Femoroacetabular impingement has been suggested to be a potential precursor to joint changes leading to hip OA as depicted in Figure 6. Figure 6: Femoroacetabular Impingement to Osteoarthritis Spectrum Femoroacetabular Impingement
Altered Joint Junction
Labral Lesions
Chondral Damage
Osteoarthritis
to conservative measures including anti-inflammatory medications and modalities, activity modification, and strengthening exercises. Tendinopathy and tears of the abductor tendon of the hip are now more frequently being recognized in patients with lateral hip pain and abduction weakness (Yanke, Hart, McCormick, & Nho, 2013). The incidence of the tears has been shown to increase with age, the presence of OA, and the occurrence of trauma (Yanke et al., 2013). Conversely, although gluteus medius tears typically cause lateral hip pain, an occult tear can contribute to a Trendelenburg gait pattern that may make a physician or physical therapist suspect problems involving the joint itself. Partial gluteal tears respond to anti-inflammatory medications and modalities, combined with activity modification to avoid overstretching the affected muscle and the initiation of a strengthening program. Full thickness tears may require surgical reattachment of the gluteus medius tendon onto the greater trochanter (Domb, Botser, & Giordano, 2013). Although painful, this condition does not directly affect the hip joint; therefore, THA is not indicated when these tears are the confirmed source of pain. It is important to keep these presentations in mind, because they may be present in the patient who has had a THA and therefore can affect the outcome of the rehabilitation.
SURGICAL INDICATIONS
THA is most frequently performed for patients with end-stage hip OA. At this time the degeneration to the joint surfaces is so advanced that motion without pain is no longer possible. Osteoarthritis More than 75% of patients undergoing THA do so because of a diagnosis of hip OA (American Joint Replacement Registry, 2014). Where OA is present, it can be due to genetic predisposition, repeated wear and tear, or previous joint injury, such as a labral tear or hip dislocation. OA of the hip joint presents with thinning of the articular cartilage and possible development of bone spurs (osteophytes) leading to pain and altered weight bearing on the lower limb. However, objective
However patients with diagnoses such as femoral neck fracture, rheumatoid arthritis (RA), and avascular necrosis may also undergo this surgical procedure (Mellon et al., 2013).
signs of OA as seen on radiograph do not always correlate well with a patient’s symptoms or functional level (Kumar et al., 2013). While labral tears and FAI were discussed previously, a third anatomical precursor for early hip OA is developmental dysplasia of the hip (DDH). This is the most prevalent developmental childhood hip disorder, and it can encompass a spectrum of anatomical variances both to the acetabular and femoral components of the hip joint. There is known to be a strong genetic link with the development of DDH. The authors of
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Book Code: PTNY3622B
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