Good afternoon, everybody. Thank you for coming. I'm sorry for the little technical difficulties here, but I think we're able to proceed. I have a few announcements to make on behalf of the academy here. First, welcome to the session. Thank you again for coming. Reminder, cell phones and audio or video recording, remind participants and faculty to silence their cell phones. Yes, for all sessions except workshops, announce that audio recording is taking place within the room. Evaluation forms, please fill out your evaluations at the end. They will help with future planning for the academy next year in San Diego. The session evaluations are located in the mobile app and the online agenda. And then I think you can get your CME directly after getting your evaluations in, so that's a good thing too. And there's also that reminder to visit the PM&R Pavilion, presuming it's still open after this, so please check out the opportunities that are free to all the attendees here. And also please pick up your Physiatry Day T-shirt at the Member Resource Center. All right. With that, I'd like to welcome you to our session here, Hip Joint and Tendon Update From to Back. I'm your session director, Dr. Gordon. Our faculty include myself, Dr. Jason DeLuigi from Mayo Clinic in Arizona, Dr. Melinda Mindy Loveless from University of Washington, and Dr. Mary Caldwell from VCU in Richmond, Virginia. So I'm going to begin talking a little bit about the hip and briefly touch on our agenda of approach to hip arthropathy. I'm going to talk about joint anatomy a little bit in thinking about different types of joints. Some joints are known as synarthrosis, a functional synarthrosis, and those have no movement. They're rather fibrous. They're very close together. They can interlock. They're extremely strong joints, and it's designed to prevent movement of bones against other bones. So examples of those kinds of joints are suture joints, like between the bones of the skull, a gomphosis, which is basically the joint that binds your teeth to your bony sockets. And then there's cartilaginous synarthrosis. One is called a synchondrosis, which is a rigid cartilaginous bridge between two articulating bones, the example being that that you would see at the sternum and your vertebra. And also there's the synostosis, also seen as an immovable joint created when two bones fuse and the boundary between them disappears. Then there's an amphiarthrosis where there's little movement, not a lot of movement. Examples of this would be like the syndesmosis in a high ankle, for example, between the tibia and the fibula, and then the pubic symphysis as well. And these articulating bones, they're connected by, you know, stiffer collagen fibers or cartilage. And then we talk about other joints being a functional diarthrosis. The hip joint is a diarthrosis. Predominantly they are synovial joints. They permit a wider range of motion than do other types of joints, as I aforementioned. And they're typically located at the ends of long bones, such as those of the upper and lower limbs. So to recap, you have the synarthrosis, which don't move, the amphiarthrosis, which kind of move a little bit, and then the diarthrosis, which are more free-moving. And so when we talk about arthropathies of structural joints, any disease affecting a joint, as opposed to an arthritis, which is merely inflammation in a joint, you know, there's inflammatory arthropathy, infectious, traumatic, immune, neuropathic, diabetic, enteropathic, and crystal. So there's many different ways to cause joints a lot of distress and disease. The biologic microenvironment of joints, we learn more and more about it every day, and there are both anabolic and catabolic processes that occur in these joints. They can cause healing, they can also have adverse consequences and, you know, destroy and hurt cells that you otherwise need for that joint and joint space to thrive. So, you know, there's mediation of stem cell migration, there's differentiation in specialized joint cells that can be affected one way or another, and these are merely a listing of a lot of different factors that are involved. Trophic and angiogenic modulators such as TGF-beta and VEGF, they promote osteophyte formation. And then, you know, there's also cytokines and other growth factors that can also, you know, directly affect bone and joint chemistry. So these variations in the biologic milieu, basically a synovial versus a cartilaginous versus fibrous and bony fused joints, where we're thinking about the synarthrosis versus the diarthrosis, those more static joints, they're less reliant on that fibrocartilaginous biology and the biolubricants. I mean, you have this built-in stiffness, whereas the more dynamic in the synovial joints, you're going to see more, I think there will be more of an effect of, you know, that biologic milieu we're talking about. There'll be, there's more lubrication, more cushioning, higher pressures on bone due to the dynamic nature in everything, the joint fluids, you know, the viscoelasticity, all of this can be affected by the biochemistry going on in there. So moving to the hip joint, which is a diarthrosis, it's a ball-and-socket synovial joint. It's formed by this articulation between the pelvic acetabulum and the head of the femur. It's designed for stability and weight-bearing and dictated by the stability primarily by osseous components and articulations. And it's really, whereas I did tell you that diarthrosis and synovial joints are largely designed for a large range of motion, the hip tries to rein that in a little bit, and it's in part because of the ligamentous structures and, you know, the weight-bearing it has to support. So different aspects of the hip here, so within the acetabulum, around it actually, is this horseshoe-shaped fibrocardiolagenous ring called the labrum. It wraps around the acetabulum, helps keep the femoral head in place, provides low transmission. It's kind of like, it causes a little bit of a vacuum seal, so it kind of sucks the ball of the femur in place there. Regulating synovial fluid hydrodynamics, increasing the depth of the acetabulum so it covers more of the femoral head surface, and together that creates more joint stability. Now there are different ligaments involved with the hip joint. There's one intracapsular inside the acetabulum known as the ligament to the head of the femur that runs from the acetabular fossa to the fovea of the femur. It also encloses a branch of the obturator artery which helps supply the femoral head. Then providing more of the stability are three main extracapsular ligaments. There's the iliofemoral and the pubofemoral ligaments that are more anterior. The iliofemoral ligament helps prevent hyperextension. It runs from the anterior inferior ischial spine to the intertrochanteric line of the femur. It's the strongest one, and then the pubofemoral ligament runs from the superior pubic ramus to the intertrochanteric line of the femur as well, and that provides more anterior inferior reinforcement. Then on the other side, the posterior, is the ischiofemoral ligament that provides that support, that posterior reinforcement going from the greater trochanter to the body of the ischium. And these ligaments together have a spiral orientation that also contributes to the stability and actually becomes tighter when the hip joint is extended. It's really hard to extend your hip, and that's part of the reason why. So the vascular supply is mainly supplied by the medial lateral circumflex arteries, the anastomose at the base of the femoral neck, they form a ring. There are smaller arteries that then go into the femoral head and supply the blood supply to the femoral head, and damage to that is largely responsible for what we know as avascular necrosis. Then as far as innervation of the hip joint goes, in the front, more anterior, the femoral obturator nerves are more responsible, and then posterior, the sciatic and superior inferior gluteal nerves are more responsible for the posterior innervation. The three major more well-known hip arthropathies that we are familiar with, femoral acetabular impingement, hip labral tear, and hip osteoarthritis. I'm just going to go over these in a cursory manner. FAI, as you know, there's a premature or an altered contact between the acetabulum and the femoral head. It causes repetitive microtrauma, and when it becomes more symptomatic, it could be due to labral injury or other abnormalities inside the joint. You get restricted hip motion out of it, you get weakness with hip flexion, external rotation as well, and a number of maneuvers and physio exams, such as Faber, Fader, and Logrol, Stinchfield, can help with the diagnosis of FAI. And on x-ray, you can see cam and pincer deformities. The cam deformity versus the pincer deformity can show either a flattened head-neck junction or a pistol grip deformity at the proximal femur, respectively, and you can also get a combined presentation of the two as well. Hip labral tears, that's when that fibrocardial laggis labrum becomes disrupted. It can cause a lot of pain, it can be a result of FAI, it can be a result of arthritis, and talking about hip arthritis, that's the degenerative process whereby the cartilage breaks down, you get sclerosing of the bone, mechanical overload, and a degeneration of the joint with synovial changes. Just to touch briefly on a regenerative approach to arthropathy, the main things we use for the hip, I think, are PRP, sometimes stem cells, sometimes dextrose and prolotherapy. In prolotherapy, you're basically injecting this irritant hyperosmolar dextrose that stimulates this low-grade inflammatory response, which seems to help stimulate the cytokine cascade and other factors in the joint that help promote some degree of tissue proliferation, perhaps healing. As you know, in the PM&R Journal, we've published new nomenclature for PRP looking at platelet counts, leukocyte counts, red blood cell counts, and how they're activated. Leukocyte-poor PRP is thought to be more preferable in joints. I think the evidence in knee is a bit more compelling where it's reducing pain, and this is actually the subject of our next guidance statement after spasticity for the AAPM&R. We're actually looking at biologics of the knee and osteoarthritis here. While in fellowship, I actually looked at using PRP in hip labral tears, and that was found in a small case study to increase function, reduce pain. Whether this is causing material changes in restoration of the actual labral tissue, that's up for debate. I think there's certainly a usefulness for PRP and dextrose in pain relief in these kinds of situations. Then again, you can look at stem cell lineages as well. With that, I'm going to turn it over to our next speaker, who is Dr. Cleveless. We are going to go ahead and move around to the lateral hip, and I'm going to review some pathology and treatment there. Objectives is just a review of the anatomy, go through the differential diagnosis for lateral hip pain, and then review some pathologies and management strategies. Just starting with a review of the lateral hip anatomy, and actually, of course, as you can see, this is a posterior view of the hip, but we want to look at the gluteal muscle, so I wanted to show this posterior view. The most superficial layer here from the posterior aspect is the gluteus maximus. You can see the gluteus medius here, which is our next layer. As we take the gluteus maximus away, you can see the gluteus medius running from the iliac crest to its distal insertion on the lateral aspect of the greater trochanter. If we take that away, then you can see the gluteus minimus, and it's deeper and slightly more anterior with its insertion on the anterior portion of the greater trochanter. These muscles function to provide a lot of stability to the hip, and now that's thought to really be the primary action of these muscles, is more in hip stability. We always refer to these as the hip abductors, but there's thoughts that that may not be as much the primary function, although it is a secondary function, and hip internal rotation is another important function of those muscles. If we look at the view from the lateral aspect, here we have the gluteus maximus posteriorly. Anteriorly is the TFL, tensor fascia lata. The TFL inserts on the iliotibial band and continues distally to its insertion on GERDI's tubercle at the anterior lateral tibia, and there are also fibers of the gluteus maximus that are inserting on that IT band as well. The TFL functions in hip abduction, internal rotation, and flexion. And then important to remember the innervation for these muscles as well, which is the superior gluteal nerve, which has supply from L4 to S1 nerve roots, so keep that in mind. If we look specifically at the anatomy of the greater trochanter, this hopefully is something that you're all familiar with. You've seen this image multiple times as I think it's been recycled and adapted through many studies looking at greater trochanteric and lateral hip issues. There are the three bursa, the trochanteric or subgluteus maximus, the subgluteus medius, and subgluteus minimus bursa, and these are all running deep to their named sort of muscle or tendon. At the posterior facet, the posterior bony facet of the greater trochanter, there's no tendinous insertion there, but over that area is where the greater trochanteric bursa is. The gluteus medius tendon inserts both on the superior posterior facet and the lateral facet, and you can see that insertional pattern here on the right. The anterior portion of the tendon is a bit thinner, and that's thought to be why that area is a little bit more prone to tears, and then the gluteus minimus is inserting on the anterior facet, and deep to that will be the subgluteus minimus bursa. You can see that insertional pattern here. Now differential diagnosis. You can see here that I've got the lumbar dermatomes shown, and I think it's really important that we don't forget about lumbar spine when we're thinking about pain in the lateral hip region. There'll be a lot of overlap in presentation of problems from the hip and the lumbar spine, so always important to think about the lumbar spine. As we just mentioned on the anatomy slide, these lateral hip muscles are getting innervation from the L4 to S1 roots. Those are the most common areas to see pathology in the lumbar spine. So if you've got a radiculopathy, you've got spinal stenosis, often you'll have weakness in those innervated muscles as well, and any weakness or dysfunction in those muscles can contribute to lateral hip pain as well, and so just important to think about that as part of the, when you're thinking about pain in the lateral hip. Of course, intraarticular hip pathology can also present with pain laterally, and then the things that we'll talk about today, greater trochanteric pain syndrome and external snapping hip syndrome. So just starting with a case to present here. So someone coming in 65 years old, three months of lateral hip pain, and CDS onset without injury. They have pain at the lateral hip with some spread distally. Pain is increasing when they're lying on that side, and then going upstairs, that's become much more difficult for them. They deny any low back pain or paresthesias. On exam, you note, as in this image, they've got a bit of a Trendelenburg gait, so that contralateral hip drop when they're on the affected side. You might also see that they compensate a bit and have an ipsilateral trunk lean instead. They may tender to palpation over the more superlateral portion of the greater trochanter most commonly. They'll have pain and difficulty with active hip abduction. They likely will have full hip range of motion, maybe some pain with external rotation as you start to stretch those lateral hip structures. And then we have a normal neurologic exam. So you might diagnose this patient with greater trochanteric pain syndrome. The pathology involved here is pathology primarily of those gluteus medius or minimus tendons. This is generally a degenerative condition, so you get tendinopathy, and that may progress to tears and atrophy of the muscle as that progresses over time. Many people compare this and liken this to rotator cuff pathology of the shoulder. It's very similar, you can call this sort of rotator cuff of the hip. There is sometimes seen calcifications in the tendons, similar to the shoulder as well. And you may see bursitis, so in those bursa, which are shown sort of in the gray here, those are those bursa, you might see bursitis, but generally the real pathology is within the tendon. And when they've done some studies looking at MRI, there was this one study that I have here of 120 patients with chronic lateral hip pain. Two thirds had no signs of bursitis and only tendon pathology. Nearly the remainder of the other third had tendon pathology with some signs of bursitis or inflammation, and only 2% showed isolated bursitis without any tendon pathology. So important to keep that in mind. The terminology in the past for this condition has been trochanteric bursitis, but generally we've sort of shifted to this greater trochanteric pain syndrome because the tendinopathy really is the problem here. So some clinical features, we already went through a lot of this just in my case presentation, the lateral hip pain, trouble with abduction, walking, stairs. They may also describe some feelings of hip stiffness during the night or when they get up in the morning and get going. Demographics, generally more women than men, and that's thought to be just a little bit due to the differences in anatomy with the wider pelvis in women. The fourth to sixth decades are most common. Again, this is a degenerative problem, so we're generally seeing that just with age and tendon wear. Some associated risk factors, increasing gynoid adipose tissue, so more adipose around the hip girdle. Low back pain can be a contributor again. Any hip instability or hypermobility, and hip and knee arthritis, also common to see sort of lateral hip pain and dysfunction in the setting of hip arthritis as well. And then some anatomical factors such as leg length discrepancy, acetabular version, and femoral head-neck angle. Exam, so we went through some of this in the case presentation. I'm gonna talk about a couple of the more special tests that have been presented in the literature. The top image here is showing what's called the hip lag sign, and so the hip is brought into some extension and abduction with slight internal rotation, and the knee flexed about 45 degrees. The examiner removes their hand, and the patient is asked to maintain that position. And if the foot drops more than about 10 centimeters, that's considered a positive sign. In the article that published this, they recommend repeating it three times just because it's not the most reliable test, but it does correspond to gluteal tendon pathology, both tendinopathy and tears. And then we already talked about Trendelenburg. The single leg stands for 30 seconds, so if they have difficulty with that, that's a sign of gluteal tendon pathology or weakness in those muscles. If they have pain with a Faber test that lateralizes, or localizes to the lateral hip, then that's considered a positive test for this. And then there's the resisted internal rotation test and the resisted external derotation test, which are basically the same thing. The only difference between these two in the studies that proposed them is the amount of external rotation that you start the patient in. So both tests, you have the patient's hip and knee flexed to about 90 degrees. And then in the internal rotation, resisted internal rotation test, you externally rotate to 10 degrees. In the resisted external derotation test, you maximally externally rotate the hip. And then just asking them to push into internal rotation while you resist them. Reproduction of pain or weakness with that is thought, again, to indicate a problem with the gluteal tendons. And then again, as I already mentioned, don't forget the lumbar spine. Make sure you're performing a good neurologic exam of the lower extremities and a full hip exam as well, as you can see coexisting hip pathology along with greater trochanteric pain. Imaging to evaluate. We've got options for x-rays, ultrasound, and MRI. On x-ray, you're mostly wanting to rule out other pathology. Make sure there's no fractures, especially if there was any history of any trauma or fall. And then it can also demonstrate some calcifications adjacent to the greater trochanter. On ultrasound, you can evaluate for pathology in the tendons and bursitis. If they have a higher BMI, more adipose tissue in the area, ultrasound can be a little bit more challenging. It's, of course, user-dependent. MRI can also help to evaluate for all of these things, as well as get a better look at muscle atrophy and has a pretty high accuracy in diagnosing gluteal tendon tears. So on x-rays, the first x-ray on the left shows a normal hip, and then the next one here is showing a calcification adjacent to the greater trochanter. So those are things that you might see, not that common, but you might see. You could also see some cortical irregularity along the greater trochanter, which can be indicative of tendon pathology, as well, at its insertion. And then this is an ultrasound image of the gluteus medius tendon at its insertion in long axis and then in short axis. And we're seeing a calcification here within the tendon in a tendinopathic tendon, both in the long and short axis. Here are some MRI images showing tendon tears with associated fluid because of that tendon rupture, both in a coronal and axial view, and then a coronal view here on a T1 showing that associated muscle atrophy. Same thing here on the contralateral hip on this MRI image. Treatments, there's various treatments, kind of similar to how we treat many different things. So starting often with exercise and physical therapy to address any underlying kind of biomechanical issues, work on strengthening of the hip girdle, stretching. Medications, of course, can be used for any pain relief if needed. And then interventions is always kind of the big topic. And so different options from less invasive to more invasive. So shockwave therapy, I think, is being used more and more as a non-invasive way to treat these types of pathologies and does show good long-term benefit, with some studies looking out at 15 months and showing good benefit. There's option, as well, for tenotomy, injection of some other substance, whether that's autologous blood or PRP or other orthobiologics. You can also, if you've got a tear, you may not consider tenotomy, but also just injection of orthobiologics like PRP. And that has also shown good benefit in long-term studies out to two years. And then the introversal steroid injections. And so, of course, steroids, we try to minimize as much as we can, especially in the setting of tendon pathology and around tendons. All the studies looking at these, and especially in comparison to other treatments, show, yeah, they likely do provide some short-term pain relief, but after about a month or so, there's no differences with other treatments and no long-term benefit. And so, always cautious with use of steroids. And then, I'm not often sending patients for surgeries for these, but there are surgical treatments that exist if they fail conservative measures. This is just one trial, just showing the summary here of this study called the LEAP trials, published several years back, comparing education and exercise to one steroid injection to just a wait-and-see approach. And there wasn't really a whole lot of difference between the exercise group and steroid groups at 52 weeks, but their rating of pain was best for those that were in the education and exercise group. So, doesn't seem to show much benefit to steroid here. So, another reason to consider avoiding steroid for these. And this is just an ultrasound image of what that needle tenotomy would look like. So, this is a gluteus minimus tendon here in long axis, and showing the needle approach into the tendon. And that tenotomy would be making several passes of the needle through the tendinopathic portion of the tendon, again, with or without injection of some substance along with that. My thought is that this helps to encourage sort of rebuilding of the tendon with fibroblast proliferation and reorganizing the collagen and tendon healing. And then, surgery. So, there's some different things they can do. They can actually repair the tendon, debride, vasectomy, but of course, there's risks. So, trying to avoid surgery if we can. All right, second case here. So, ballet dancer presenting with pain and snapping at the lateral hip. Atraumatic onset, gradually worsening, and they describe a snapping sensation that occurs with stares and walking. So, we would diagnose here external snapping hip syndrome, not to be confused with internal snapping hip. This is the snapping of either thickened IT band or anterior gluteus maximus muscle over the greater trochanter. My thought is just we're due to a sort of repetitive activity there. You can see this in asymptomatic individuals, and it may be present in up to 5% to 10% of the population, and there may be a component of bursitis as well. You can see here's the IT band on the image here, and then the gluteus maximus, and that would be snapping over the point of the greater trochanter. Again, slightly more in women for this, and risk factors, hypermobility, and repetitive physical activity, especially in extremes of motion like ballet, soccer, running especially. On exam, again, you're gonna wanna look at their hip, but the main thing you wanna do is reproduce their snapping. The snapping is often palpable. It's sometimes visible, but rarely audible. The idea is you wanna move them into repetitive flexion and extension to reproduce that snapping, and then one thing that I read about in some of the literature was the hula hoop test. So, basically, you just have them stand and reproduce the motion of what they would do if they were hula hooping, and so just repetitive sort of motion of the hip to reproduce that snapping. If you apply pressure over the greater trochanter, you're sort of blocking that snapping motion, and so that can reduce the snapping, so that's another test that you can use to confirm your diagnosis, and then the OBRA test to evaluate for IT band tightness. On imaging, both MRI and ultrasound are options to look at the structures in the lateral hip for this. On MRI, you might see a hypertrophy gluteus maximus or tight IT band, with or without surrounding hyperintensity, and you could see some greater trochanteric bursitis as well, and then the nice thing about ultrasound, of course, is that we can use it for dynamic evaluations, so you could look at the lateral hip as you move into flexion and extension and look for that snapping, and then that also allows you to see which structure, whether it's gluteus maximus or IT band, and that's just a showing sort of a cartoon image as well as an MRI image of the two different potential pathologies here, one being this tight IT band, which you can see here on the MRI, or the other is a hypertrophied anterior gluteus maximus, which is this sort of bundle of muscle right here. Treatments are somewhat similar to what we've already discussed, so rest from aggravating activities, exercise and physical therapy, medications for pain relief, injections, consider a greater trochanteric bursa injection if they're really acutely painful, and then there are surgical options out there as well for failure of conservative measures. That's it. Thank you. Perfect, thank you everyone for coming to our talk today. I get like the middle talk, so I'm gonna try and keep you guys awake. I'm a ball of energy, so I'm sorry if you feel like I'm yelling. I just apologize in advance. Really passionate about the hip, genuinely love it. I take care of runners almost all day, every day. I'm really lucky to have kind of my dream practice, but a jack of all trades. So this is gonna be simplified for those of you that don't do sports medicine all day, every day, like me, I want something to stick, right? And then for those of you that do do sports medicine all day, every day, I am sorry if it seems very basic, but I wanted to keep some key points. So posterior hip pathology, when we talk about it, there's five key things I want you guys to keep in mind. So obviously, like Dr. Loveless said, we're thinking about the spine, we're thinking about the sacroiliac joint, all of that lives in that area. In fact, when people come in and they say, they don't say my posterior hip hurts, they say, I've got back pain or I've got butt pain, and then they point to the posterior hip, which we know as the posterior hip, but no one ever comes with that chief complaint. Deep gluteal pain syndrome, which I'm gonna have encompass piriformis syndrome. Abdominal and pelvic referral, don't ever be fooled, always think outside of the box, it is not always gonna be straightforward. Ischiofemoral impingement syndrome, and then hamstring tendinopathy. Those are the five key things I think I see most commonly, those are the things I picked, but there's obviously a large differential, and it will see you if you're not thinking about it, so don't forget these things, vascular, infectious, neoplastic, degenerative, iatrogenic, congenital, autoimmune, traumatic, and endocrine. Just don't forget the broader differential, please. So posterior hip pain, just like everybody said, and reviewed a lot of this anatomy already, so I'm not gonna get into that, it's critical to any diagnosis, it's the key for everything. If you're not getting a good history, you're not gonna get the right diagnosis, so don't skip the history, have a system, and that's often where the answer lies. The exam must always, always include a joint above and below spine, hip, and knee, because if you don't do that, again, you will miss something. Treatment, almost all of these cases that I'm going to talk about do great with physical therapy. I think we all know that as PM&R physicians that that's gonna be the case, but we can also consider medications, NSAIDs, which we don't need to get into the evidence of, muscle relaxers, neuropathic pain medications, depending on the path the course takes. Consider x-rays, always, consider ultrasound, always, MRIs, diagnostic and therapeutic injections, that really depends on where you practice, what kind of practice you're in. Can you get away with a lidocaine shot and get the ultrasound still covered by insurance? Probably not if you're in academics, but if you're in private, you might have a little more wiggle room for that, right? So it kind of depends on what kind of practice you own and where you work. Blood work, EMGs can be considered ABIs, lots of tests can aid in diagnosis, and then don't forget your differential. So this slide has a lot on it, but this is kind of the key slide for the talk. We're gonna talk about, again, these five things. So posterior hip pain, the first thing to think about, intra-abdominal or intra-pelvic, right? So just really basic, key history, urinary or bowel symptoms, did they recently just have a baby and they're coming in with pain? Do they have a history of prostate issues? Do they have a history of prostate cancer? Could they by chance have endometriosis? Could there be an ovary problem, right? Don't forget the stuff that lives in the pelvis. In your exam, that would be a basic abdominal or pelvic exam, if you don't do pelvic exams and that's not part of your training. I work really closely with OB-GYN and we share a lot of patients, and so if I feel like something is pelvic, they'll often add that patient on for me that day and we work closely together on pelvic floor pain if that's the issue, and same with urology and urogyne. When we talk about deep gluteal pain syndrome, so shifting, this is gonna include that deep buttocks pain, renamed, and this includes, for me, piriformis syndrome, right? Because what is piriformis syndrome? We could spend like days on that. Worse with sitting, especially in the car. Theoretically, they come in and say, I've got sciatica, I've got piriformis. So many people come in with that chief complaint and I'm just like, I don't think that's it. Burning pain, shooting down the leg. There is a test called the seated piriformis stretch test. Sensitivity, about 80%, and it says specificity, 90%. You would have the person sitting, their leg would be in extension and you would actually internally rotate the leg and so you'll feel, and they'll feel a stretch on that piriformis and it should reproduce their symptoms. That's just one of the tests that you could use to work on deep gluteal pain syndrome. Ischiofemoral impingement syndrome, so differential number three for me. And I realize there's six things on this slide. Now you guys think I can't count, but anyway. Ischiofemoral impingement syndrome, so gradual onset of deep buttocks pain. This is that person that comes to you and they say, hey, I'm taking a long stride. This is often what they say as a runner. And when I take that stride, I feel pain right in this side of my butt. And they point to where their lesser troch is and in between their lesser troch and their ischium. And it's often just as simple as that. The person will say they're taking less, like they're taking shorter strides to try to compensate for the pain. And they're like, fix me, what are you gonna do? And it's been years that they've had this pain typically. And it takes some time to reverse and it's that quadratus femoris muscle getting pinched when it happens. And you can do that long stride walking test. It's as simple as it sounds. You have them lunge, and when they lunge, they feel pain on that opposite side of the lunge, right between that ischium and the lesser troch. So lumbar spine, like Dr. Loveless spent some time talking about, is involved often, right? So pain in the low back, usually above L5, in the hip and the buttock region. It can radiate, right? And they might have a history of lumbar problems before. Tenderness usually is over that area on exam. Don't forget your neural tension signs, seated slump, straight leg raise. Often those can be the key, especially in really fit athletes. I often find sometimes they just present with what they're calling hamstring pain and they have no back pain and they just have buttocks and hamstring pain. And it's the back. Sacroiliac joint pain, really important. Usually there's no history, theoretically, no history of lumbar spinal issues. I think the two go hand in hand, but usually they're pointing to right over that sacroiliac joint, and that's usually just very tender on exam. I call it the Fortin Fingers test, right? But there's lots of SI maneuvers that we could talk about and go into. And depending on the studies you look at, we know those studies aren't that great. But no tenderness theoretically above L5 when we're talking about SI joint pain. So proximal hamstring teninopathy, really, really common. You're gonna see this a lot. This could be acute on chronic. This could be chronic or this could be acute. And they basically come in and say, usually I felt a pop right here. I felt something ball up or I've got a lot of pain and I felt it on an overstride. And there should be tenderness to exam over that ischial tuberosity. But also when you test the hamstring, you should be able to provoke it and test it in multiple positions. If you only test it in one position, for example, I love my residents and they're all here, but if you only test it and they're in a seated position and that's how you tested the hamstring, that's not gonna work for me. Lots of other muscles were involved. You need to test it in not only like a supine position. I test it with the leg. If they're in a supine position, I test it when they're prone. I test it with the knee bent. I test it with the knee straight. I really try to provoke that hamstring because oftentimes I find the hamstring is just mimicking something else. Okay. I included on here a picture of, I don't know if you can see my mouse. I'm so sorry. On the right is just a picture of ischiofemoral impingement because I won't have another picture of it. And that's the pinching between the ischium and the lesser trope. And then on the bottom is a typical ultrasound picture when you're looking at that proximal hamstring tendon. CT stands for conjoined tendon. And then you can see the ischial tuberosity there. On the left side of that screen is the disease side and on the other side is the normal side. And it's pretty easy to scan a hamstring in the office. And so I'll include that almost all the time if someone's presenting with what I think is hamstring. So now we're gonna do some fun cases to wake y'all up. So case one, 28-year-old with two years of posterior hip pain. So this person came in and they said, hey, I've had pain for two years, but in the last two weeks it's gotten a lot worse. It hurts really bad when I walk, worse with changing positions, worse in the morning, no red flags, and then maternal grandma has a history of RA. Everything else in the history was negative. Exam is notable for me with positive SI joint pain. So I do an X-ray in the office. This is his X-ray. The X-ray looks pretty normal to me. I have other views, but this is the view I included here. So the differential things we talked about, right? This to me fits SI pain, but consider inflammatory arthritis. You could consider a strain of the joint or dysfunction. Less likely lumbar pathology, annular disc tear, less likely deep gluteal pain syndrome. This one seemed pretty straightforward to me. But I put him on a short course of NSAIDs. I send him for some physical therapy. I always have my patients follow up. I'm really lucky in that that I can get them in because I have a lot of slots that I try to squeeze followups into. And so I have them come back at four weeks. PT, he says, helped some, 10%. I re-reviewed the X-ray. He said the NSAID helped as well, about 50, 60%. And so at this point, I'm like, you know, I really need to do more for this kid. And so I get some advanced imaging in some labs, and this is his MRI results. So he has acute sacroiliitis with an erosion. I get his, and you can see that by the T2 signal on the SI joint on the left side, which is right where his pain was. I review the MRI with him. I get some basic autoimmune blood work, and his HLA-B27 is positive. I diagnose him with inflammatory arthritis, you know, likely ankylosing spondylitis, and I place a referral to Room. The wait for Room is about six months. I start him on treatment with diclofenac, 75 milligrams BAD, and I consult one of the rheumatologists via Epic so that I can get this guy some care while we're waiting for him to be able to get in. He continued physical therapy. He's continued on the medication. He's doing much better. Other things I would have considered for him is you could do an injection if you needed to, if I could not control his pain in the meantime, but he's doing great. Okay, case two. 47-year-old with posterior buttock pain. So this is a weightlifter and a runner, and she comes in, and she says she's doing squats, and the next day she noted some pretty severe posterior buttock pain with radiation into the hamstring. She says sometimes it goes down the back of her calf, but she denies any back pain. She says she was diagnosed years ago with piriformis syndrome. This is her piriformis. Please inject my piriformis or I'm not leaving your office. So I say, okay, let's go back. So she reports she can't walk due to severe pain. She has no other red flags. She says Tylenol's not working. Motrin's not working. Ensigns aren't working. She's been to urgent care twice. She's gotten two Medd-Roll dose packs. Flexoril is not helping. No PT. I do my exam. I say this is not your piriformis. You've got pain over your mid buttocks, but your seated slump is part of your straight leg. Rises positive. You can't flex your back without severe pain. This is from your back, and I don't think it was probably ever piriformis syndrome, but oftentimes that's the challenge is convincing them that you're doing your job correctly. So for me, diagnosis is likely disc pathology. Sure, I'll throw piriformis out there. Maybe it's kind of a double crush thing, but sciatic deep gluteal pain like we've talked about. Know your differential. Images, I do an X-ray in the office. It looks great. I did do FlexX, which I usually will do if someone's having that severe pain. Try to get the best images I can, and plus it occurred with squatting, and she's an athlete. I do an ultrasound of the posterior hip really more to humor the patient because I want her to trust me also, but I also need to show her that I don't think this is the piriformis, and I don't think the sciatic was entrapped. That was normal. I did change her to Roboxin. I put her on Meloxicam. Lots of studies go into this, which we're not gonna get into, but you don't have to do both of them. You could choose one of them, and both of them have really mixed evidence. Sent for PT ASAP to work on her sciatic and nerve glides in the lumbar spine and the piriformis, and I had her returned to office about a week or two later. So she came back to me, ongoing severe pain. At this point, she's having difficulty getting to work. She is a professor at one of the colleges in town, and she's having a lot of difficulty teaching, so I decide we need to escalate this care. Let's see if we can get her in for an intervention, possibly an epidural. So I get her MRI, and you've got one view here, and you can see the rather large L5-S1 disc herniation that showed up on her MRI, and it was actually paracentral, but it was also pushing more to the right side. Given she had no radiculopathy, we did, and she didn't want to go right for surgery, which I don't blame her. Sometimes these do really, really well with conservative care. She's young, she's healthy. Two epidurals later, she gets absolutely no improvement in her pain. Physical therapy's not helping her turn the corner. She ended up having to go to neurosurgery for decompression and from the severity of the pain, and she's doing wonderful. So case three, 45-year-old triathlete with one-year posterior buttock pain. You guys are starting to see a theme. So pain in the right buttocks with sitting, standing, walking, running. Constant, worse with activity. She reports pain at the top of her hamstring area. It's better with stretching. Despite nine months of PT and the hamstring work and eccentrics, ongoing pain. Some low back pain. She has a history of scoliosis. NSAIDs always help her pain. Tylenol helps rest health, but when she takes weeks to months off running, she still can't get back to training because her hamstring's bothering her. She was referred to me because she wanted to try PRP in her proximal hamstring versus an ischial bursa injection. So I do my exam. She's got some tenderness over the proximal hamstring at the attachment of the ischium. That's all correct. She's got some weakness with hamstring testing manually, but there's no cramping. I could provoke that hamstring every which way and I could not get that hamstring to act up. And so I said to her, I don't think this is your hamstring. So I changed my exam to focus more on her back. You guys are getting a theme, right? She's got a positive seated slump and a straight leg raise. And I said, well, it's probably your back. We do images of her. We do x-ray. I do an ultrasound in the office of her hamstring. She had a little bit of cortical changes, but she's a triathlete and she's, what, 40? So she's gonna have some old overused stuff there. But I'm still not convinced. So I send her for a change in her physical therapy. I haven't really focused on a McKenzie approach with her low back and possibly still add some hamstring stuff in. Maybe we need to do more at it. Maybe see if it was a deep gluteal, like a piriformis involvement, but that didn't make sense. And so I was kind of needed PT's help. They see her. They can't tease it out. They send her back to me. She's still not getting better. She does the nerve glides. She says, oh, maybe they're doing a little bit, but nothing big. She says she's still getting severe pain. She can't run. So this time I said, okay. I'm gonna do more because this is a really fit athlete and I have to figure out what we're gonna do. Where am I gonna try an injection? Where am I gonna make her better? And there it was. So I do the MRI of her lumbar spine. It's completely normal, but I do the MRI of her pelvis and I missed it. So it was an ischial tuberosity stress reaction or an early stress fracture in her ischium, which had been there for about a year. You know, I tell my residents, it's always a stress fracture in a runner until proven otherwise, and I missed it. But there it is. It showed up. You can see it on the imaging. And so even I forgot my own rules. But she is doing great. We actually had to make her non-weight bearing for six weeks because she's taken time off, but you can imagine how much force goes through the pelvis when you're walking. She's doing excellent. She's in the process of a pain-free return to run. So in summary, you have my six things on a slide. So intra-abdominal or intra-pelvic deep gluteal pain syndrome, ischiofemoral impingement, lumbar spine referral, sacroiliac joint pain, and then the proximal hamstring. I think those are still your most common, but don't forget your vindicate mnemonic of all the other things you will see, or you will miss something. All right, thank you. Thank you. Well thank you, Dr. Gordon asked me, Jason DeLuigi can talk about the medial hip, medial anterior hip and specifically athletic pubalgia, nothing to disclose. So I still consider that part of the overall anterior hip pain as the referral pattern from that standpoint, so always going to start with the differential diagnosis, as talked about earlier, osteoarthritis, the inflammatory arthropathies there, additional muscle pain and or tendon strains and tendonitis, femoral neck stress fractures, again the one here, sports hernia from that standpoint or athletic pubalgia or again hernia of the oblique, pononorosis, obturator or angle of nerve entrapments as well as osteitis pubis, acetabular labral tear, so again for the focus of here, we're going through the aspect. So one of the things you're going to go through when you're going through an overall algorithm here is the injury insidious or spontaneous, some of the things you're going to be asking for, is there any other systematic issues or symptoms that you may be having versus being short lived or specifically linked to a trauma as you're bringing through the cascade, so again age is going into it and some of the differentiations or other ongoing comorbidities, so it depends on getting your referral source and how they're presenting initially here as well, so from that standpoint as you're going through the different aspects of it, so specifically when you're talking about more of the groin pain, you're rolling out the intra-abdominal and intra-pelvic lesions as well as making sure it's not any referred pain from that standpoint that may be coming from elsewhere. So going through the overall athletic pubalgia specific aspect of it as you've gone through that diagram there, a lot of times they'll be talking about pain that's in their groin over the pubic bone, sometimes it's in the lower abdomen as well, oftentimes it causes significant discomfort, they might be limping, a number of people try to play through it, I always remember one of the ones from back in the day, Donovan McNabb, when he was quarterback with the Eagles, had continued to try to play through what was called a sports hernia and he was definitely not able to push off with his throws, it was causing discomfort and I remember he threw an interception and they ran him back for a touchdown and he took about three steps to try to go make a tackle and he just stopped and that was like the last game he played before he went and had surgical management of it. But if there's something you're suspecting here, from that standpoint, whether it's occurring acutely on the field or if it's coming to your office, you're looking for overall potential tenderness of palpation in that area and what that area would be is going to be where it's going to be the abdominal musculature inserting into the pelvis, the adductor musculature inserting into the pubic bone as well and it's that aponeurosis or tenderness that lays right over that pubic bone. But one of the things you're also going to look for, just again, make sure, rule out, is that there's not an actual hernia, right, so sports hernias typically aren't true hernias where we talk about where you have a bowel that's going to go into, through the abdomen for like a transverse plane abdominal strain where you have a bowel that's going to come through the abdominal musculature or it's not going to be a direct or inguinal hernia. But you still need to rule those out from that standpoint. Many times you may have co-incident injuries with this, right, so that may also be causing pain or may be the cause of the pain itself, right, so adductor tendinopathy and or osteitis pubis. So as you're kind of going through and looking at the, you know, the way the anatomy is and structured there, you have the erectus abdominis and then you have the adductor, right, so together they have a conjoined aponeurosis which just goes over and adheres to the pubic bone there. And so you're going to be scanning, you know, if you're going to be looking for, depending on the extent of the tear, it can be on the rectus side, it could be on the adductor side, or it could go across, you know, to parts of the rectus and the adductor and through the entire aponeurosis. So, you know, imaging, you know, again, I'm leading with ultrasound, so again, stepping away from just our general musculoskeletal ultrasound. If there is a potential concern for a true hernia, you would be also ordering, you know, a either, you know, ultrasound rule out hernia from that standpoint as well. So, you know, many times when you do that, they're not going to be scanning the MSK side of it, right, so that would be something that if you are doing ultrasound, you may be able to do if that's within your skill set or you would send to a colleague that may do it, whether it's a musculoskeletal radiologist or another PM&R colleague who does that diagnostic ultrasound of the groin and pelvis. So when you're looking for it, you would be able to do a dynamic and static evaluation, right, with both either a hernia or with the MSK side of it. So if you're doing a valsalva maneuver while you're looking and scanning, you could see separation if it's the abdominal tissue and having a herniation through the abdominal fascia that may have been torn. But also, if you're looking for an inguinal hernia, by doing that valsalva maneuver, you would be able to see their direct or indirect inguinal hernia. If those are ruled out, I don't personally do hernia evaluations, so, you know, for me to look at it and specifically try to look for a hernia, I've done, you know, if there's a, I've had prior patients where they have had a, you know, abdominal hernia before and then it re-tore, right, so they asked me to look at it, you know, it was sent to me for that and you would have the valsalva and you'd see the bowel come through, but those aren't things that I normally would see and look at in order as a, you know, just coming to my office, but since he had prior surgery there and had the issue, but, you know, I would not look at that, so I still tend to send my, you know, hernias for the scrotal hernias or looking for, you know, scrotal pathology or hernias, you know, sending it there because that's not something that I routinely look at, but for the MSK, I do, you know, so, you know, it's very difficult, it can be difficult to get good visualization, you know, with, at times, it's going to be important to do a proper setup, you know, many times the patient already has pain in that area, it's already sensitive and tender and it's in a sensitive area already, so you really have to get the, you know, probe, you know, deep into the, you know, medial anterior hip, so where it's going at or over the pubic bone, you know, depending on the overall, you know, sensation, sometimes it may be easier to start at the abdomen and coming down to the pubic bone and then, you know, kind of, so they're getting used to you doing the ultrasound at that time and then coming down to the lower extremity and then doing it there, so what you're going to be looking for here is, you know, changes and findings, you can also then have them AD-duct their hip against resistance while you're scanning, right, and or do that Valsalva for the abdominal side, so you'll be able to look at both, so, you know, where times it still may be beneficial if they didn't already come to you with an MRI, depending on, again, how they presented, you know, if this is something that's chronic pain and they, like, look, rule out alphaletic pubalgia, they may have already had it, but, you know, an MRI would be important, again, to rule out some of the other things that we were talking about in that initial differential diagnosis, so here's some of the, you know, more visual, you know, aspects of it where you're having, you know, pathology here, again, you have that rectus abdominis and the adductor tendinosis there, so you see the changes that are over the pubic bone, you see the cortical irregularities there, you see the fluid and the separation of tissue in that top picture compared to that bottom picture here, it looks, you know, that's an extended field of view there where you can see that rectus abdominis coming into that, and the superior aspect of the superior pubic rami, and then the adductor lung is coming in on the inferior aspect, but right there, you know, where that arrow is on that second side is a lot of times where you start to see it, it's right at that adductor insertion into that conjoined aponeurosis. Here's an example of a complete tear that you may see from that, where the adductor does pull completely off the bone and you have significant retraction, you know, from that typical proximal footprint back to, you know, retracted several centimeters back here with that, and you see the fluid that accumulates in that area as well, you know, so what would be the treatment? Again, it's going to be, you know, based on, you know, the overall, you know, extent of tear and problems, again, how long it's been going, whether they've already tried, right, so, but if you are seeing a fresh, you know, mild to moderate, you know, obviously not a complete adductor tear, you know, they may give, improve with a trial of some relative rest, getting back into some physical therapy, working on strength, flexibility, range of motion exercises, whether it's alone or if you're going to supplement that with a needle-based treatment, so, you know, there has been some, you know, studies and case studies, not very large, you know, from that standpoint, is, you know, randomized controlled studies were utilizing PRP injected right at the site of the tear in the aponeurosis with PRP or prolotherapy, and they have been shown to be both effective, you know, again, as single agents, but most times with physical therapy alone. Many times where you'll start to see when you're really hearing about the sports hernias, they are doing repairs, so a lot of them will progress through a repair because then you have to figure out who's doing them in your area, right, so many of the orthopedic surgeons don't consider that something that they do, many of the general surgeons don't consider it something that they do, right, because they're like, it's not a true hernia, we don't see it, and some of the orthopedists say, well, that's more of a general surgery issue, go see general surgery, so if this is something that you see or concern, you frequently encounter, can find out in your area who may be doing some of those, you know, they can be done with or without mesh, you know, so I've treated a number of persons who have had surgical management of their sports hernia, and then they've had a lot of irritation and scar tissue from the mesh, you know, in that area, and so some of them have had the mesh gone back and they tried to remove the mesh, but then also sometimes I've had, on numerous occasions now, I've had other entrapment neuropathies of either ilioinguinal, iliohypogastric, general femoral, you know, in that area, depending on, you know, where the mesh was placed and the extent of the tear and from that standpoint, and then they would have recurrent symptoms of medial groin pain, and, you know, part of it was, you know, the person is like, did it come back, did I re-tear, and you look for further assessment, you know, from that standpoint and, you know, working with the tunnels or over those nerves or potentially even trialing either a singular block or like a transverse abdominal plane block where you're able to get all of them in that same fascial plane at times as a diagnostic, so there was one patient who was a professional soccer player, you know, from that standpoint who had the repair, had the problems come back, was having issues with their post-operative recovery and so then they had me, you know, do ultrasound guided singular isolated nerve injections to see with lidocaine and then they were having him go work in our sports performance area and he was dribbling the ball and making kicks and then we would come back another day and try a different nerve to see if that had helped. We were able to kind of isolate it so when we sent it back to the surgeon, you know, for, you know, one of the trapment neuropathies, you know, to see if they can go in and clean it up in that area. You know, another option would have been doing almost like a hydro dissection at that area in time but, you know, before I went and did that at the post-operative management, we wanted to go back and see the surgeon with him being a professional athlete and the surgeon wanted to try to see if they can clean it up without doing a hydro dissection at that time. So, any questions for the group? I guess we'll open up the floor to questions. Well, thanks guys. Thank you.

hip pain

groin pain

posterior hip pain

deep gluteal pain syndrome

ischiofemoral impingement syndrome

lumbar spine referral

sacroiliac joint pain

athletic pubalgia

diagnostic tests

treatments