[Flash 10 is required to watch video.]renderVideo(“video_player_8341204362”,’http://thegaitguys.tumblr.com/video_file/8341204362/tumblr_lp8c0blhUj1qhko2s’,500,281,’poster=http%3A%2F%2Fmedia.tumblr.com%2Ftumblr_lp8c0blhUj1qhko2s_frame1.jpg,http%3A%2F%2Fmedia.tumblr.com%2Ftumblr_lp8c0blhUj1qhko2s_frame2.jpg,http%3A%2F%2Fmedia.tumblr.com%2Ftumblr_lp8c0blhUj1qhko2s_frame3.jpg,http%3A%2F%2Fmedia.tumblr.com%2Ftumblr_lp8c0blhUj1qhko2s_frame4.jpg,http%3A%2F%2Fmedia.tumblr.com%2Ftumblr_lp8c0blhUj1qhko2s_frame5.jpg’)

A Case of Hip pain in a Young Runner: Perthes Disease

here is a nice little short video of a young girl with a healed Perthe’s Disease (full name, Legg-Calve-Perthes Disease) that came to see us a few years ago with right hip pain.  After an examination and a very brief treatment stint films were obtained and found an early stage Perthe’s Hip.  Early diagnosis is always important in this disorder that affects the vascularity of the head of the femur. Failure to make an early diagnosis is a disaster which leads to deformity and permanent disability for the patient.  Perthe’s affects mostly male boys under the age of 10. There is really no clear etiology but many studies point to a period of increased pressure within the joint from an inflammatory process. A term “Transient Synovitis” has been labeled by some.  In this case, the disorder was caught in its first stage and the hip revascularized, did not collapse and it is doing well.  Collapse is the most devastating outcome of this disease process, it is why you do not mess around with children with unresolving hip pain, obtain imaging early.  The main problem, as is seen here, is that she cannot get to her gluteal muscles to stablize the hip in the frontal plane.  Here you see a classic Trendelenberg Sign when she steps onto the right leg. 

When she steps onto the left hip the hip,knee and foot are well aligned in the frontal plane and the right hemipelvis rises above the left hip joint line.  Comparatively, when she steps on the right, there is a significant lateral pelvic and body mass shift beyond a line drawn up from the foot-knee line.  Consequently the left hip drops and she looks like she has a short right leg.  Measurements (as unreliable as they are)  do not show a leg length discrepancy.  However, this type of mechanical behavior can put undue stress on a healing femoral head.  Using a sole lift to help regain pelvic leveling during gait help maintain balanced femoral head pressures and cartilage coverage during the last stages of joint formation in this adolescent.  The problem is that there will be dependency on the lift so regular daily exercises with guaranteed compliance is imperative.  She must regain use of the glute in gait and stance or this hip will be a problem in later years, guaranteed.  So, this is a difficult case.  It is not for the faint of heart.  Bottom line, do not mess with kids with hip pain for long without imaging to rule out terrible problems like this.  There are so many gait problems that will ensue if the gluteal stability is not regained.  To name just a few, the right foot will always be supinated and this means risk for bunions (see last weeks Dr. Ivo video on bunions and the adductor hallucis muscle) and other disorders that are caused by an unanchored first metatarsal.  Additionally, the knee can degenerate the lateral compartment quickly not to mention the plethora of muscular problems (low back pain, knee pain etc) and strategies (ie. pelvic distortion patterns) that will ensue from such a gait.  There is so much more to Perthes Disease than we have mentioned here, but this is not the venue for such complicated topics.  The important thing is to beware of systemic problems that can compromise the integrity of the neuromusculoskeletal system that can have short and long term effects on one’s gait. Here is a link to some more info on Perthes Disease …… but even this is scant info (http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002244/)….. make sure you do your reading if you are in the clinical world and see young patients. 

It is not always just about muscles and shoes and orthotics. You have to always be on your toes (no pun intended).

we are…….. so much more…….. than just Gait Guys.

ARS: Acetabular Rim Syndromes.  Hip Pain. 

Some examples of MOI’s (Mechanism of Injury)

-An athlete complains of a gradual onset of pain deep within his or her anterior groin.
-Forceful kicking a ball with the medial border of the foot may cause a sharp pain with a catching sensation.
-A case involving a ballerina with 10 months of left hip pain originated during a high kick in the abducted position; she felt a sudden catching sensation in the anterior left groin.
-A car accident with knee dashboard impact forcing femur posteriorly.
-A wrestler in a quadruped position forced back onto heels (buttock to heels)

Labral lesions have a strong correlation with
 anterior inguinal pain
painful clicking
transient locking
giving way of the hip
Pain may be reproduced with flexion and internal rotation of the hip
An audible click may also be present
The patient history usually does not reveal significant trauma
The onset of pain may be related to sports and may involve a mild twisting or slipping injury
Radiographs in patients with labral tears are typically unremarkable.
If early osteoarthritic disease is present, the pain is out of proportion to the radiographic changes.

While the pain is usually in the groin, it could also be in the trochanteric and buttock region. A significant trauma is not necessary to disrupt the labrum – twisting or falling may be causative. The injury is usually caused by the hip joint being stressed in rotation. The pain could be acute or insidious. The most common complaint is discrete episodes of sharp pain precipitated by pivoting or twisting. Clicking or catching is common but not always present. Activities that involve forced adduction of the hip joint in association with rotation in either direction tend to aggravate. The majority of labral tears (up to two-thirds) are located anteriorly.

Their hip pain is often nonspecific regarding symptoms.
Radiological findings may be negative.
It is important to rule out early any possibility of fractures, infections, inflammation or ischemic necrosis; laboratory tests of blood, urine and at times synovial fluid may be necessary.
Acetabular dysplasia, considered pre-osteoarthritic by some, is a valid clinical entity that must be considered.  Some references are calling this disorder dysplastic acetabular rim syndrome (DARS).

Early symptoms will occur due to overload of the acetabular rim caused by hip motions such as a combination of flexion, adduction and internal rotation.
Getting out of a car or doing the breast stroke are examples of this type of movement stress.
 Snapping, locking and clicking are common in ARS, causing the clinician to think of problems related to the labrum or a painless snapping iliopsoas.

Snapping hip complaints must be discriminated from functional hip problems such as anterior femoral glide syndrome and IT Band syndrome.
Symptoms due to hip instability may be related to ARS.
The patient may suffer unexplained falls or the feeling that his or her hip may give way.
With acetabular dysplasia, there may be excessive anteversion of the femoral neck, causing an increase in hip internal rotation on examination. The capsular pattern of the hip that indicates osteoarthritis is almost always a decrease in hip internal rotation. Therefore, as soon as osteoarthritis appears, decreased hip internal rotation will also appear.

We are going to leave things here for today…….we wanted to leave you with 3 words for the day……..INTERNAL HIP ROTATION.  Keep these 3 words in your clinical hat for the day, look for its loss and start thinking about your runners, your patients.  Look for this loss when the patient is supine and in the straight leg position.  Test the hip rotation from spinning the hip (from an ankle contact point) into internal rotation, compare side to side. 

More tomorrow ……but remember, sometimes it is not the part……but the anchor for the part….. hence why we will be talking about the lower abdominals as the week goes on. The amount of Internal hip rotation available is only as much as the abdominal wall can support or anchor (ie. a weak abdominal wall cannot support much functional internal hip rotation…….. why ? tune in tomorrow ! as we bring this full circle.)

……….. we are more than…….Just The Gait Guys

The Myopathic Gait:

This gait abnormality is sometimes referred to as a waddling gait. The waddle or shift is secondary to proximal pelvic musculature weaknesses.  The client may utilize a limb circumduction strategy to compensate for the weakness in the gluteals or as seen better here displaying an exaggerated alternation of lateral trunk movements with an exaggerated elevation of the hip.  There are some distinct similarities to the Trendelenburg gait pattern.  There are several causes of this gait variant, some of which are temporary and some of which are orthopedic and some neurodegenerative.  For example: pregnancy, hip dysplasia, muscular dystrophy and spinal muscular atrophy.