Hip Assessing hip pain in primary care Professor Sam Adie

In this podcast, Professor Sam Addy, an orthopedic and trauma surgery specialist at the University of New South Wales, provides a comprehensive overview of hip pain, particularly focusing on its assessment within primary care settings. With a solid foundation in orthopedic surgery and extensive research experience, Professor Addy outlines the epidemiology, causes, and management strategies for hip pain, setting the stage for a nuanced understanding of this common ailment.

The lecture begins with an exploration of the epidemiological factors influencing hip pain, particularly in older populations. Drawing on data from the Australian Joint Replacement Registry, Professor Addy highlights that the incidence of hip replacements primarily occurs in individuals aged between 55 and 75, predominantly due to osteoarthritis. This age-related trend underscores the importance of recognizing not only age as a risk factor but also the interplay of genetics, lifestyle choices, and previous injuries that can predispose individuals to hip disorders. Professor Addy points out other less common causes such as inflammatory arthritis and avascular necrosis, emphasizing the need for a broad differential diagnosis.

Moving forward, Professor Addy discusses the critical symptoms and signs associated with hip issues, including pain and functional limitations. He details how the pain often radiates from the hip joint to surrounding areas, particularly the groin and thigh, and warns clinicians to remain vigilant for pain indicators that may suggest non-hip-related diagnoses. The significance of a patient’s functional state is stressed, as the impact of hip pain varies substantially across different patient demographics. Tools like the Oxford Hip Score are introduced as valuable resources for assessing the functional impairment caused by hip disorders.

Assessment of hip pain is presented as a multi-faceted process, where a thorough patient history forms the core of accurate diagnosis. Professor Addy emphasizes the importance of understanding the nature of the pain, previous treatments received, and any co-morbidities that may complicate the clinical picture. His insights extend to the physical examination process, where he advocates for assessing gait, joint motion, and conducting targeted imaging studies such as weight-bearing X-rays, prior to resorting to advanced imaging like MRI or CT scans.

The discussion then transitions to non-surgical management strategies for hip pain, underscoring the importance of foundational treatments that should be implemented before considering surgical options. Professor Addy advocates for patient education, regular physiotherapy, and exercise as primary interventions. He encourages patients to adopt a proactive approach to their condition, noting that lifestyle adjustments and maintaining physical activity can significantly enhance quality of life.

Professor Addy outlines clear criteria for when referrals to specialists or surgical intervention may become necessary. He identifies persistence of joint-related pain despite conservative management, confirmatory imaging showing arthritis, and significant functional impairment as key indicators that should prompt specialist consultation. Additionally, he conveys his personal observations about the variable outcomes of surgical interventions, particularly noting that while hip replacements can offer substantial relief and high satisfaction rates for patients, outcomes can be more unpredictable compared to other joint surgeries.

In conclusion, Professor Addy encapsulates the essence of hip arthritis management by highlighting that a clinical assessment remains paramount, and that while conservative treatments are foundational, timely referrals can optimize patient outcomes. His insights serve as a guide for primary care providers, emphasizing the necessity of a structured approach to diagnosing and managing hip pain effectively.

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Next up, we have Professor Sam Addy. Professor Addy is a professor of orthopedic

and trauma surgery at the University of New South Wales.

He specializes in surgery of the hip and the knee.

He's got a vast research background and has won numerous awards for his research

and runs a series of clinical trials to improve outcomes after joint replacement and injury.

Today, Professor Addy will be speaking about addressing hip pain in primary care. Thank you.

Thanks so much, Mike. So I am just going to give you a really brief overview

or even a recap of hip pain and how to assess hip pain.

And I think Raz next is going to talk more about the treatments available for the hip.

So I am a founding surgeon partner at the Orthopaedic Institute at Macquarie University Hospital,

So this is an outline of the talk So just some background

to the evaluation of hip pain Just going to talk about a brief recap of the

epidemiology and the causes And then some talk about the symptoms and signs

some differential diagnoses that you may want to consider the types of imaging that we can order,

non-surgical management so I'm going to focus a little bit on that in this talk

and then also when to think about referring to a specialist.

So epidemiology, I think the best way to really show this is by what happens

to people at the end stage of their hip arthritis, right?

So if you look at the Australian Joint Replacement Registry,

the people that are having hip replacements for that severe end of the spectrum

for arthritis are very much in the older age group.

So you can see here that the older you are, the more likely it is that you'd...

Let's see if I can get this point to working. so

the older you are so say you know

the younger age groups less than 55 but also

at the other extreme end of the spectrum are less common but

then you know the older age groups between 55 and

75 are the ones that are having the bulk of these operations and the vast majority

of the diagnoses are still osteoarthritis but if you do look at the younger

age groups it's usually something else as well so still osteoarthritis is by

far the most common even if you're young,

but then there's other diagnoses that occur when when

you're in the younger age group and i'll explain why that might

be the case in a second so osteoarthritis still

most common reason you know it's probably a combination

of genetics lifestyle factors obesity

has been associated with hip arthritis as well and it's probably you know those

repetitive injuries that occur over a lifespan okay and they just haven't had

a chance to appropriately heal

and then just like any sort of overuse or chronic wear and tear problem.

You have this ongoing wear and tear of the joint that results in osteoarthritis,

Other causes of hip arthritis that we should consider are the inflammatory arthritis

so rheumatoid seronegative disease, avascular necrosis.

And in western society including Australia of course alcohol and corticosteroid use,

are by far the most common causes of avascular necrosis so again a rare but

important cause of hip pain that can then lead to secondary hip arthritis.

And then you've got these sort of, you know, group of developmental problems.

Okay, so I've just grouped them here as all as these developmental problems.

And these are things that, you know, occur when you're younger in your childhood.

So when you have developmental dysplasia, perthase disease, a slipped epiphysis.

But essentially with all of these conditions, what's happening is

the patient has grown or has developed some

sort of abnormal shape to their hip and we'll

just show a picture in a second but basically if you have an abnormally shaped

hip it's not going to function as efficiently as normal and normally as you

know a normal ball and socket joint and then you get your risk of getting that

early degenerative change and then there's other causes as well so infection, trauma,

tumor that are sort of again sort of less common causes but should be considered

when you're thinking about hip pain so this is an MRI scan of what avascular

necrosis looks like you know sometimes you won't see this on an x-ray so you

know if you suspect it that's the reason for why you may want to order further imaging.

And then you've got this condition called femoral acetabular impingement which I'm sure most of the.

And we're not entirely sure what actually causes it, but it's probably some

sort of developmental thing. You know, people have it when they're younger.

You know, they've done studies where they've just done a whole bunch of x-rays

on, you know, a cross-section of the population. And a certain proportion of,

you know, even younger patients would have these changes.

But you can see, as I alluded to before, that instead of having a nice smooth

ball and socket joint, you've got this sort of like more egg-shaped sort of

appearance of the proximal femur.

And you can see how that sort of lump or the cam lesion what's termed the cam lesion in FAI,

can put a lot of additional strain on the joint when that articulates with the

socket and this is sort of you know what I said about these other conditions

that sort of change the shape of the hip so if you have you know you know you

have a history as a child of,

developmental dysplasia or perthase disease it sort of results in these abnormally

shaped you know proximal fevers or even the acetabulum and instead of that nice

smooth ball and soccer you've got the abnormal shape that then predisposes you

to getting those early degenerative changes.

So a little bit about the pathophysiology, about why this happens.

So, you know, the people who do this research would make a lot of effort to

remind us that, no, this is not really a disease of old age.

It's not just wear and tear, okay? because there is a pathophysiologic process that's happening,

where they essentially get an imbalance of the factors that are regenerating

the cartilage and doing damage to the cartilage.

And I don't want to dwell on this too much because there's not much clinical

implication to it at this stage.

I'm not aware of any sort of medication

or treatment that can change that imbalance that I'm alluding to.

But essentially what seems to be the key is these things called matrix metalloproteinases,

and they are responsible for sort of the upregulation of the breakdown of cartilage.

And it's a complex interplay as you can imagine of all of these sort of like,

you know, other factors.

And then that leads to all of these other things. So it starts with cartilage,

but then it leads to, you know, bone changes and osteophyte formation and the

joint space narrowing that we would see on an X-ray.

So let's talk about symptoms and signs. So the key, I guess,

key cardinal symptoms would be pain and stiffness.

That's a recurring theme in arthritis, right? Pain and stiffness of that joint.

And then that then leads to all of these other things.

So gait disturbance and limp is really as a result of the pain and stiffness

that occurs in that joint.

And then that leads to a functional deficit.

And that's probably you know

one of the obviously pain no one wants to be in pain but then

the other really really important factor to consider for the patient

is how much impact that's happening on their

sort of you know their function now that's different

for different people so you can imagine the function say

of you know a little old lady in her 70s

is quite different to a working age male

in their 50s so just important to

consider what that patient's functional needs are

and what they actually want right because again

what they need will also influence the type of management that we do from a

non-surgical or surgical perspective and i've put up here it's hard to see sorry

but you know it's it's the oxford hip score so have you guys heard of the oxford hip score,

It's one of the many patient-reported outcome measures that you can find for the HIP.

Very, very commonly used one. It is routinely used in the Australian Joint Replacement Registry.

But if you can see some of the writing there, what it's asking about is just

very simple questions about day-to-day activities.

It's like, you know, in the past four weeks, have you been able to put on a pair of socks?

How long after a meal sat at

a table has it become too painful

for you to stand up from a chair because of the hip so

these are really simple day-to-day activities that the Oxford HIP score is then

asking about and you can do an eventual score depending on their answers and

then that then gives you an idea about how disabled they are According, you know,

comparatively to the rest of the population And because Oxford hip scores have

been done on millions and millions of people You've got very good sort of,

you know, psychometric data to compare to,

I should say metric data to compare to.

Yeah, so that's the functional deficit And then you have deformities And they're

things like leg length discrepancy or contracture,

So how do we assess it? The key would be really the history, okay?

So pain and function, I just mentioned. So a little bit about the pain,

because I think the nature of the pain here, especially if we're talking about hip pain in general,

and we want to try and focus on, you know, whether this is actually coming from

hip arthritis or the hip joint itself, the nature of the pain becomes important.

And I do see quite regularly, And I'm sure colleagues in the room,

Mike and Raz would agree that often we get sent patients that,

you know, with the diagnosis of hip pain or hip arthritis, but it ends up being something else.

And I'll get to some of the differential diagnoses, but the pain from hip arthritis,

generally speaking, is centered around the joint.

Okay. So the groin, the buttock region, the trochanteric area,

so sort of around that joint.

It can be referred. So you can get referred pain down the thigh all the way to the knee.

And there's that classic description of someone presenting with knee pain with

hip. So you can get that. So it can go all the way down your thigh.

But rarely does it actually go below the knee. So that's the classic teaching.

And I think that reflects what I see in clinical practice as well.

So if you get someone that has points to pain that sort of radiates down their

thigh, all the way down their leg, think of an alternate reason.

And same thing if it radiates upwards as well. So if the pain is sort of around

the hip and it sort of radiates around from their back or radiate up their back or low back, again,

I would definitely start thinking of an alternate reason and maybe that's the

patient that you may want to arrange further investigations for.

Okay I talked a little bit about

the functional state already and I think the other

key thing from the history is to see what for me

anyway is to see what treatments they've had so far

right because obviously they're in my sort of zone of influence as a surgeon

and they're seeing me because they've been referred to me to have potentially

have surgery and I need to know what other treatments they've exhausted first

before we dive into doing something potentially sort of, you know,

risky and invasive like an operation.

And then obviously asking about comorbidities is going to be important to that.

So examination, I actually find hip examination pretty simple.

So first of all, look, assess their gait, walking aids, look at other joints,

feel not so useful around the hip because it's quite a deep joint,

so you're not going to be able to really feel the hip.

You can feel other bony prominences, so the trochanteric bursa or the trochanter.

You can definitely feel other joints like the knee.

Or possibly the iliac crest or something else that might be generating the pain

but you can't really assess the joint itself then move,

and then moving we're looking at flexion extension abduction adduction the issue

with those movements is that they can be,

generated by other joints around the hip so

the one that's pretty specific to

the hip is rotation so if they have any restriction

of rotation that's probably coming from the

hip and in investigations weight-bearing x-ray

95 of the time is going to be enough okay and then like i said if you suspect

those other diagnoses if you suspect something else is going on you want to

exclude that that's when you would get you know other scans ct mri please please don't do those off

that just do the weight-bearing x-ray first and then if that doesn't really

show anything it's very unremarkable you have got some suggestion from the history

or their background of something else going on sure refer them for that other test okay.

So differential diagnosis, again, I sort of alluded to these a little bit.

I'll just skim through some of them. So it can be intra-articular.

So intra-articular problems that are not arthritis can definitely cause some hip pain.

So I would suspect those in someone who has a pretty normal-looking weight-bearing

x-ray, but a history or an examination that suggests that it's emerging from

the hip, again, that's when I would refer them for additional tests, MRI. right?

Periarticular structures, so trochanteric pain, stappic hip syndrome.

You know, they usually, again, from history examination.

Referred pain, I sort of already discussed, and then other things like stress

fractures and avascular necrosis.

So non-operative treatment.

So we would ideally really rely on you to, you know,

lead some of this before they actually see

us right and the college of gps has

excellent guidelines for the management of um hip

and knee osteoarthritis so i'm not sure if you guys have seen it

it's probably too detailed if anything but there's been

a lot of work gone into it that people have assessed all

of the data and the evidence and they've given recommendations about you know

about each of the different modalities that you can have and there's a there's

you know there's you know heaps of treatments available for arthritis everyone

wants to sell something when it comes to treatment for arthritis because it's such a common problem.

I guess what we shouldn't lose sight of is the first-line approach, okay?

These are the three things. So the reason I mention that is because it's amazing.

Even us surgeons, like the first thing we do is we'd send them for an injection

or prescribe some pain relief, right?

And you sort of lose sight that the first-line recommendations,

the ones that have the strongest evidence, are these three things.

So the first thing is education and this

is just telling them explaining what the problem is explaining the

background of their condition and the idea behind that you know you can imagine

you're telling someone about their condition it's not going to cure their problem

right it's not going to regrow the cartilage by them knowing that they've got

hip arthritis but it's just about allowing them to develop that sort of you

know active role in their own treatment or you know self-efficacy,

so that they can sort of take charge and sort of adapt to what they've got.

Okay, so the idea really behind any non-surgical management,

because we're not reversing their condition, this is a degenerative condition,

is essentially learning to adapt and learning to live with their condition happily, right?

It's not like we want them to struggle, but hopefully get you to a happy place with these things.

Okay, so the first thing that we can do is educate them, Allowing them to develop

that self-efficacy And then you've got land-based exercise.

So that's where we can refer to physios or exercise programs And exercise definitely

has some evidence for arthritis and weight loss,

And then second line is everything else And then there's third line and other

adjunct treatments And these are all of the things that we've heard about When

we come to arthritis treatment,

Injections, you know.

Acupuncture and massage and hot and cold packs and all of these other things

that you can possibly think of is everything else.

And you can definitely try those,

right? There's no issue, but don't lose track of the first line stuff.

So, when to refer then. So for me, in my mind, there's three things.

It's pain consistent with that joint that has a significant functional impact.

Secondly, it's x-rays that show the arthritis, that confirm the diagnosis.

And then three is failure of the non-surgical treatments. So I think that's

when we think about now Who is a candidate for surgery They're really the basic

criteria For having surgery So if you have those three things,

We've made an attempt to do all of that sort of stuff In your practice That's

I think the right time to refer.

And then in terms of surgery I won't dwell on this But it's hip replacement

or hip resurfacing Is essentially the arthroplasty options I will mention though

with hip arthritis is that, yes, we should do all of this, okay,

But in most of our experience, people, once they develop the hip arthritis,

okay, they tend to, you know, do pretty badly, you know, once it's set in, okay?

So unless it's like a first presentation, you know, within that first year or

two of symptoms, and they can get some improvement with non-operative treatment,

if they've struggled for it for a little while.

It's likely that it's going to be pretty constant for them.

It's a bit different to other joints I'm

not sure if Raz or Mike would agree.

But hips do badly once the

symptoms settle in and they become quite

constant and permanent so still want

you to do all of this but unlike other

things like with a knee for example I reckon you can definitely if

people do some of the stuff with non-surgical management

with knees you can absolutely get to a really good

place okay if you lose weight and exercise absolutely

get to a good place even if your knees like bone on bone

right but with hips it's a little bit different and

the reason i mentioned that is because the surgical option

for it is really really good okay as we all know hip

replacement is a very successful procedure um

generally speaking um so you have headlines

like this in the lancet and lancet wouldn't you know

publish a paper like this um willy-nilly right

it's um so it really is one of the best operations

out there and the reason for that is because

it's just got such a high satisfaction rate and in

the rare instances where people are unsatisfied and

this is one of the studies that we did but there's heaps and heaps of studies

in the literature confirming this the people that are unsatisfied are probably

in the order of about five percent or less and it's because something's gone

bad okay and when it's gone bad hips are pretty bad So they've had a dislocation

or some sort of other complication.

That's rare And that's when they're unsatisfied,

So these are some key takeaways. Hip arthritis and its impact is mostly a clinical assessment.

Conservative treatment remains the foundation and then refer when those conservative

treatment options are exhausted.

Thanks so much.