Diagnosis

• Clinical exam 
• X-ray (AP Pelvis and lateral views)
  

Treatment

Education is the key to help patients self-manage their symptoms and adapt their lifestyle to an OA diagnosis. Promotions of general health and weight loss as well as exercise are mainstays in the management of hip OA.  

Avoiding passive therapies and focusing on self-help and patient-driven treatments are approaches that have proven effective. Group and home exercise programs should be considered. Hydrotherapy, aqua-fit or cycling should be recommended. Adherence to a program is the principal predictor of long-term outcome from exercise in patients with OA. It is therefore important to discuss patient likes and preferences when it comes to exercise.

Conservative treatment

The first line of treatment should be conservative measures including:

• Rest and/or activity modification
• Physiotherapy
• Custom orthotics or over the counter insoles (eg: Superfeet) - if necessary
• Prescription of a walking aid
• Weight loss
• Use of NSAIDs and/or pain relief medication. Opioids are not recommended in the treatment of OA.
• Low impact exercises
• Cortisone injection
• Hip injections should be performed using X-Ray or ultrasound guidance
• Many sports medicine doctors in the Champlain LHIN use ultrasound to guide injections. Usually it is faster to obtain an injection from sports medicine as opposed to using the diagnostic imaging department at any hospital.

Physiotherapy can help with further education, symptom management, gait analysis, prescription and education about mobility aids as well as proper fitting, general strength and proprioception exercises. Such an approach is proven to help with fall risk prevention also. Treatment should focus on promotion of physical activity and general health. The physiotherapist will help with pain control, hip mobility exercises, hip, core and general strengthening exercises, assess gait and balance and possibly suggest a walking aid (e.g.: cane) if necessary.  The therapist will introduce non-weight-bearing exercise options such as swimming, aqua-fit and cycling as well as a home exercise program.

Surgical treatment

Surgical treatment is indicated for patients with pain and loss of function despite a trial of conservative treatment. The choice is either hip resurfacing or hip replacement. Hip resurfacing is generally only considered in men <50 years old.

Physiotherapy is recommended after surgery. A typical rehabilitation program will last 12 weeks.

Diagnosis

• Clinical exam 
• x-ray  
  

Treatment

Babies or children up to the age of 18 with DDH should be referred to orthopedics at CHEO.

Adults with DDH should be referred to the Central Intake for consult.

Conservative treatment

Conservative management is often helpful to delay or to relieve pain until surgery is performed. Non-operative treatments are chosen when the condition is caught early and there is minimal damage to the joint.

The first line of treatment should be conservative measures including:

• Weight loss
• Heat/ice
• Activity modification (avoid running, stair climbing, impact sports)
• NSAIDs (Advil/Ibuprofen) or pain relief (Tylenol/Acetaminophen) medications. Opioids are not recommended
• Cortisone injection
• Hip injections should be performed using X-Ray or ultrasound guidance. Many sports medicine doctors in the Champlain LHIN use ultrasound to guide injections. Usually it is faster to obtain an injection from sports medicine as opposed to using the diagnostic imaging department at any hospital
• Low impact exercise (swimming, aqua-fit)
• Physiotherapy

Surgical treatment

Surgical treatment choices of DDH in the adult are hip arthroscopy, osteotomy, hip resurfacing or hip replacement depending on the patient’s age and condition.

Diagnosis

• Clinical exam
• X-rays  
  

Treatment

Conservative treatment

The first line of treatment should be conservative measures including:

• Rest and/or activity modification
• Weight loss
• Use of NSAIDs or pain relief medications. Opioids are not recommended
• Physiotherapy
• Cortisone injection
• Hip injections should be performed using x-ray or ultrasound guidance.
• Many sports medicine doctors in the Champlain LHIN use ultrasound to guide injections. Usually it is faster to obtain an injection from sports medicine as opposed to using the diagnostic imaging department at any hospital

A cortisone injection into the hip joint can help relieve pain but can also be used as a way to diagnose the hip issue.

Physiotherapy treatment should focus on exercises to improve hip mobility, core and lower extremity strength, improve posture and general fitness, as well as suggest low/no impact activities such as swimming, aqua-fit and cycling.

Surgical treatment

Surgical treatment is arthroscopy of the hip if FAI is caught early. In this region, the procedure is rarely done on anyone over the age of 40 and the patient should have no arthritis in the hip joint.  Otherwise, if conservative measures fail, the treatment is hip resurfacing or hip replacement depending on patient’s age and condition.

Hip pain in young adults should not be considered normal. It most often presents as anterior groin pain for intra-articular hip pathology and is usually related to hip position and/or movement. Labral pathology is often the cause and commonly goes undiagnosed for an extended period of time. The patient may see many health care providers before being diagnosed on average 2 years after the onset of pain. It is most common in females.

Most common causes of persistent hip pain in young adults are femoroacetabular impingement syndrome (FAI), hip dysplasia, and early osteoarthritis.

Early referral and treatment can improve pain and function but might also enable joint preserving treatments before the onset of osteoarthritis.

It is important to note that labral tears may represent a natural condition in an aging joint. Labral tears have been found in patients without hip pain. Their presence increases with age. In cadaver studies, labral tears and abnormalities were found in 93-96% of hips. (Groh)

A predictable pattern of muscular imbalance in the pelvis tends to be factor in labral tears. This pattern being - tight hip flexors accompanied by inhibited gluteal and abdominal muscles. The imbalance leads to anterior pelvic tilt, increased hip flexion and hyperlordosis of the lumbar spine and likely short hip flexors. Patients might also present with some lumbar spine pain.  (Groh)

Diagnosis

Clinical exam - On examination, the most consistent finding is a positive hip impingement test.

X-rays should be done to look for any signs of OA, as anyone >40 years of age with more than mild arthritis will not qualify for an arthroscopic surgery to repair the labrum.

AP X-Ray of pelvis is appropriate for first line investigation for hip pain to exclude dysplasia, fracture, OA, confirm FAI type of anatomy or osteonecrosis. “A cross table view with or without a frog lateral view and a false profile view allow for specific measurements of the acetabulum and femoral head to improve recognition of subtle DDH or FAI” (Groh)

Evidence suggests frequent incorrect reporting of “normal” hip radiographs where FAI abnormalities are actually present. It might be appropriate to consider further investigation in the presence of continued pain.

MRIs and CT scans are unreliable for diagnosing labral tear. Magnetic Resonance arthrography (MRA) is the diagnostic test of choice with arthroscopy being the gold standard. An x-ray should be done first because if the patient is >40 years of age and has more than mild OA on x-ray, they would not be a candidate for an arthroscopy. 

Conservative treatment

As a first step, patients should try conservative treatment prior to consulting a surgeon. Surgery is rarely indicated for labral tears as it often fails to relieve pain and according to recent research it does not prevent the progression of osteoarthritis.
Conservative treatment of hip pain in young adults includes:

• Rest and/or activity modification
• NSAIDs and/or pain relief medication. Opioids are not recommended.
• Cortisone injection
• Cortisone injections of the hip are performed using x-ray or ultrasound guidance to ensure correct needle placement. These injections are generally done in a hospital diagnostic imaging department or by a sports medicine doctor in his office.
• Hip injections should be performed using x-ray or ultrasound guidance.
  
• Many sports medicine doctors in the Champlain LHIN use ultrasound to guide injections. Usually it is faster to obtain an injection from sports medicine as opposed to using the diagnostic imaging department at any hospital
  
• Physiotherapy
• Physiotherapy treatment can help with pain control and activity modification, gait analysis, improving back and hip movement, strengthening the muscles around the hip, back and core to address the possible muscle imbalance that could be contributing to the condition.
  

Refer young adults with persistent hip pain for orthopaedic/sports medicine specialist opinion, even if imaging studies in primary care are reported as normal

 

Surgical treatment

Surgery to repair labral tears is only done in patients under 40 who show little or no sign of osteoarthritis of the hip.  According to recent research, it does not stop the progression of osteoarthritis and there is often the need to re-operate.

Diagnosis

• Clinical exam - Patient will present with severe pain in the hip but typically good ROM unless the disease is advanced - then the whole hip joint becomes arthritic.
  
• X-Rays (AP pelvis and lateral views) have <41% sensitivity for detecting early stages of the disease.
• MRI is the most reliable and sensitive tool to diagnose AVN. MRI has a sensitivity and specificity of > 90% for early detection of AVN.
  
• CT is the best technique to determine the extent and area of bone death and is more useful in a case that is in later more advanced stage.
  
• Bone scans are sensitive but have a large number of false positives.

Treatment

It is a slow-progressing disease and the earlier it is diagnosed the better the outcome.

In early stages of osteonecrosis, non-surgical or conservative treatment is tried first. This includes:

• Physiotherapy
• Pain relief medication if indicated/as appropriate
• Pharmaceutical management to treat osteoporosis if indicated/as appropriate
  
• Use of cane, crutches or walker   
• Rest and/or activity modification

If this is not helpful with pain relief and improving function, refer to Central Intake.
Core decompression surgery can be considered for the patient with AVN. Otherwise, the treatment is hip replacement.