Normal Anatomy of the Hip Joint
The thigh bone, femur, and the pelvis, acetabulum, join to form the hip joint. The hip joint is a "ball and socket" joint. The "ball" is the head of the femur, or thigh bone, and the "socket" is the cup shaped acetabulum.
The joint surface is covered by a smooth articular surface that allows pain free movement in the joint.
The cartilage cushions the joint and allows the bones to move on each other with smooth movements. This cartilage does not show up on X-ray, therefore you can see a "joint space" between the femoral head and acetabular socket.
The pelvis is a large, flattened, irregularly shaped bone, constricted in the center and expanded above and below. It consists of three parts: the ilium, ischium, and pubis.
The socket, acetabulum, is situated on the outer surface of the bone and joins to the head of the femur to form the hip joint.
The femur is the longest bone in the skeleton. It joins to the pelvis, acetabulum, to form the hip joint.
How does the Hip joint work?
Find out more in this web based movie .
Femoro Acetabular Impingement FAI
Femoroacetabular impingement (FAI) is a condition where there is too much friction in the hip joint from bony irregularities causing pain and decreased range of hip motion. The femoral head and acetabulum rub against each other creating damage and pain to the hip joint. The damage can occur to the articular cartilage (the smooth white surface of the ball or socket) or the labral tissue (the lining of the edge of the socket) during normal movement of the hip. The articular cartilage or labral tissue can fray or tear after repeated friction. Over time, more cartilage and labrum is lost until eventually the femur bone and acetabulum bone impact on one other. Bone on bone friction is commonly referred to as Osteoarthritis.
FAI impingement generally occurs as two forms: Cam and Pincer.
CAM Impingement: The Cam form of impingement is when the femoral head and neck are not perfectly round, most commonly due to excess bone that has formed. This lack of roundness and excess bone causes abnormal contact between the surfaces.
PINCER Impingement: The Pincer form of impingement is when the socket or acetabulum rim has overgrown and is too deep. It covers too much of the femoral head resulting in the labral cartilage being pinched. The Pincer form of impingement may also be caused when the hip socket is abnormally angled backwards causing abnormal impact between the femoral head and the rim of the acetabulum.
Most diagnoses of FAI include a combination of the Cam and Pincer forms.
Symptoms of FAI
Symptoms of femoroacetabular impingement can include the following:
- Groin pain associated with hip activity
- Complaints of pain in the front, side or back of the hip
- Pain may be described as a dull ache or sharp pain
- Patients may complain of a locking, clicking, or catching sensation in the hip
- Pain often occurs to the inner hip or groin area after prolonged sitting or walking
- Difficulty walking uphill
- Restricted hip movement
- Low back pain
- Pain in the buttocks or outer thigh area
A risk factor is something that is likely to increase a person's chance of developing a disease or condition. Risk factors for developing femoroacetabular impingement may include the following:
- Athletes such as football players, weight lifters, and hockey players
- Heavy laborers
- Repetitive hip flexion
- Congenital hip dislocation
- Anatomical abnormalities of the femoral head or angle of the hip
- Legg-Calves-Perthes disease: a form of arthritis in children where blood supply to bone is impaired causing bone breakdown.
- Trauma to the hip
- Inflammatory arthritis
Hip conditions should be evaluated by an orthopedic hip surgeon for proper diagnosis and treatment.
- Medical History
- Physical Examination
- Diagnostic studies including X-rays, MRI scans and CT Scan
Conservative treatment options refer to management of the problem without surgery. Nonsurgical management of FAI will probably not change the underlying abnormal biomechanics of the hip causing the FAI but may offer pain relief and improved mobility.
Conservative treatment measures
- Activity Modification and Limitations
- Anti-inflammatory Medications
- Physical Therapy
- Injection of steroid and analgesic into the hip joint
- Hip arthroscopy to repair femoroacetabular impingement is indicated when conservative treatment measures fail to provide relief to the patient.
A hip labral tear is an injury to the labrum, the cartilage that surrounds the outside rim of your hip joint socket. The hip joint is a ball and socket joint in which the head of the femur is the ball and the pelvic acetabulum forms the socket. The labrum helps to deepen the socket and provide stability to the joint. It also acts as a cushion and enables smooth movements of the joint.
A tear in the labrum of the hip can result from traumatic injury, such as a motor vehicle accident or from participating in sports such as football, soccer, basketball, and snow skiing. These sports are associated with sudden changes of direction and twisting movements that can cause pain in the hip. Repetitive movements and weight bearing activities over time can lead to joint wear and tear that can ultimately result in a hip labral tear. Degenerative changes to the hip joint in older patients can also lead to a labral tear.
Many patients with a hip labral tear do not have symptoms. However, some patients may experience pain in the hip or groin area, a catching or locking sensation in the hip joint, or significant restriction in hip movement.
Your doctor will order certain tests to determine the cause of your hip pain.
X-rays of the hip allow your physician to rule out other possible conditions such as fractures or structural abnormalities.
Magnetic resonance imaging (MRI) may also be used to evaluate the labrum. An injection of contrast material into the hip joint space at the time of the MRI can help show the labral tears much clearer.
Injection of local anesthetic into the joint space is sometimes performed to confirm the location of the pain. If the injection completely relieves your pain, it is likely that the cause of the problem is located inside the hip joint.
Treatment for a hip labral tear will vary depending on the severity of the condition. People with a minor labral tear recover within a few weeks with the help of non-surgical treatments.
Conservative treatments include:
- Medications: Anti-inflammatory medications can be helpful in relieving pain and reducing inflammation associated with labral tears. Your doctor may also recommend cortisone injections to alleviate the pain associated with a hip labral tear.
- Physical therapy: Physical therapy that helps to improve hip range of motion, strength, and stability are also recommended.
However, severe cases may require arthroscopic surgery to remove or repair the torn portion of the labrum.
Hip arthroscopy, also referred to as keyhole surgery or minimally invasive surgery, is a surgical procedure in which an arthroscope, a narrow tube with a tiny camera on the end, is used to assess and repair damage to the hip.
The surgery is performed with the patient under general, spinal or local anesthesia.
Your surgeon will make 2 or 3 small incisions around the hip joint area. The arthroscope is inserted into the hip joint through one of the incisions to view the labral tear. The camera attached to the arthroscope displays the image of the joint on the monitor. A sterile solution will be pumped into the joint in order to have a clear view and room to work. Through the other incisions specially designed instruments are inserted. Your surgeon repairs the torn tissue by sewing it back together or removes the torn piece all together, depending upon the cause and extent of the tear. After the completion of the procedure, the arthroscope and instruments are removed and the incisions are closed.
Post- Operative Care
Following the surgery, you will be given instructions on caring for your incisions, activities to avoid and exercises to perform for a fast recovery and a successful outcome. Physical therapy will be recommended by your doctor to restore your strength and mobility. Your doctor will also prescribe pain medications to keep you comfortable.
Risks and Complications
Possible risks and complications specific to arthroscopic hip surgery include:
- Deep vein thrombosis(DVT)
- Blood vessel or nerve damage
- Hemarthrosis (bleeding inside the joint)
- Failure to relieve pain
Greater trochanter bursitis also called hip bursitis is a common problem caused by inflammation of the bursa that overlies the greater trochanter (bony prominence at the outer side of the hip). A bursa is a small sac filled with fluid which acts as a cushion and allows smooth motion by reducing the friction between the muscles and the bone. The condition causes pain in the outer portion of the upper thigh.
Greater trochanter bursitis most commonly affects runners and athletes participating in soccer and football. It is more common among women and middle-aged or elderly people. The risk factors that increase the chances of developing trochanteric bursitis include:
- Repetitive stress or overuse injury to the hip joint that may occur because of running, climbing stairs, cycling or standing for a long period of time
- Hip injury resulting from a fall onto your hip, blow to the hip, or from lying on the same side of the body for a long period
- Improper posture as a result of scoliosis, arthritis of the lumbar portion of the spine, and other spinal diseases
- Leg length differences may affect your walking pattern and can cause irritation of the hip bursa
- Disease conditions such as rheumatoid arthritis, gout and psoriasis may lead to inflammation of bursa
- Previous hip fracture surgery or prosthetic implants in the hip can cause irritation of the bursa
- Bone spurs or calcium deposits formed in tendons that attach to the trochanter may cause irritation to the bursa
Pain in the outside portion of the hip, thigh area or in the buttock is the main symptom of greater trochanter bursitis. The pain may become worse in the night, when lying on the affected side, during activities such as prolonged walking, climbing stairs, squatting. Pain may also aggravate while standing up after being in sitting position for a long time.
Your doctor will perform physical examination of the hip area and may order diagnostic tests such as X-rays, bone scan and MRI scan to rule out possibility of injury or other conditions. The initial phase of treatment of greater trochanter bursitis is non-surgical and includes simple lifestyle changes such as avoiding activities that make symptoms worse (activity modification), use of anti-inflammatory medication to control pain, and use of support from walking cane or crutches while walking. Corticosteroid injection into the bursa is also effective in relieving pain.
Surgical treatment that involves removal of the bursa may be recommended if the pain and inflammation in the bursa does not resolve with conservative treatment approaches.
Hamstring injuries are common in athletes who participate in sports activities such as track, soccer, and basketball that involve running. The three hamstring muscles namely semitendinosus, semimembranosus and biceps femoris are at the back of the thigh and helps you bend (flex) your knee and extend your leg.
Injuries to the hamstring group of muscles can range from a minor strain to a complete tear. Avulsion injury occurs when the hamstring muscle tendon completely tears away from the bone. Sometimes, the tendon or ligament may even pull off a piece of bone along with it. Tears from the pelvis are known as proximal hamstring avulsion.
Hamstring tendon avulsions are caused by a sudden contraction of the hamstring muscle during strenuous exercise. A sudden jump, overstretch, or large sudden load to the muscle can increase your risk of hamstring avulsion injury.
Patients with hamstring avulsion injury will experience extreme pain, weakness, cramps while walking and running, and poor leg control, particularly while walking down a slope.
Hamstring avulsions occur rarely and are often difficult to differentiate from simple strains. Diagnosis is made through the symptoms and physical examination. During the physical examination, your doctor will examine your thigh for tenderness and bruising as well as check for signs of pain, swelling and weakness in the back of your thigh. Your doctor may order an X-ray to see whether the avulsed tendon has pulled away a small piece of bone and MRI scan to determine the severity of your injury.
Initial treatment for hamstring injuries involves rest, ice, compression, and elevation (RICE protocol); all assist in controlling pain and swelling.
Hamstring avulsion is a serious injury that may require surgery. During the tendon avulsion repair, hamstring muscles are pulled back to its normal attachment. Your surgeon cuts away any scar tissue from the hamstring tendon and then the tendon is reattached to the bone using staples or stitches. If there is a complete tear within the muscle, the torn ends are reattached using stitches.
After surgery, you may need to use crutches and a brace to protect and keep your hamstring muscle in relaxed position. Your doctor will recommend physical therapy which involves gentle stretching exercises in order to restore normal function. Rehabilitation period of at least 6 months may be needed before returning to athletic activities.