Lateral Hip Pain - A Radiological Approach

An exploration of the aetiology of common causes of lateral hip pain and some alternative swerve ball diagnoses. The radiological anatomy and approach to investigation as well as the common appearances seen on multimodality imaging (x-ray, MR, CT, ultrasound) are discussed.

We also touch on interventional techniques for greater trochanteric pain syndrome and some of the other conditions around the hip.

Transcript

1. Dr Daniel Fascia Consultant Musculoskeletal Radiologist A Radiological Approach Lateral Hip Pain
2. About me Trained in Imperial College London and Perth WA Consultant MSK Radiogist in Harrogate (2014) Regional Clinical Lead (YIC) Director of Medical Imaging - NHS Nightingale NHS and Private Practice Illiya Vjestica via unsplash
3. What I’m going to cover Diagnostic Imaging A recommended imaging algorithm How to request imaging The role for interventional radiology Swerve balls Key points
4. Trochanteric Pain Syndrome Con fl icting terminology often used • Trochanteric Bursitis • Gluteal tendinopathy • The rotator cuff syndrome of the hip? What exactly is it?
5. Aetiology Why does GTPS happen? Friction Impingement
6. Predisposing Factors Weight Obesity Low BMI (padding) GT Morphology Curvy Hips Dysplasia Activities Gait Alteration Spine - Scoliosis, Back pain OA - hip, knee, ankle Muscle / tendon Post Surgical Limb length Muscle / tendon recovery
7. Radiological Anatomy
8. Anterior Lateral Posterior
9. Anterior Lateral Posterior Posterosuperior Facets
10. Gluteus Minimus Gluteus Medius Gluteus Medius Tendons
11. Muscles
12. Subgluteus Minimus Subgluteus Medius Bursae Trochanteric Subgluteus Maximus
13. Friction
14. Impingement
15. Bursitis is not the most common radiological finding It’s gluteal tendinopathy
16. Diagnostic Imaging
17. Plain Film Radiography Pelvic x-ray • Osteoarthritis? • Morphological features? • Enthesopathy? • Another cause of hip pain? X-Rays
18. Normal Features 
 of normality
19. Osteoarthritis Very common Diverse pain pro fi le Trendelenburg gait Exam fi ndings key Co-existence
20. Enthesopathy Pathology of attachment of tendons, ligaments or capsular structures to underlying bone
21. Enthesopathy
22. Enthesopathy
23. Enthesopathy Are Radiographic Trochanteric Surface Irregularities Associated with Abductor Tendon Abnormalities? Lenca Steinert, Marco Zanetti, Juerg Hodler, Christian W. A. P fi rrmann, Claudio Dora, and Nadja Saupe Radiology 2010 257:3, 754-763
24. Gluteal calcific tendinopathy
25. Magnetic Resonance (MR) Not usually fi rst line imaging Useful when the diagnosis is not clear More expensive Less accessible Time consuming Pros and Cons
26. Magnetic Resonance (MR) Is GTPS the primary reason for the MRI? YES - Standard hip MRI NO - Depends on indication Which Protocol?
27. Magnetic Resonance (MR) Is GTPS the primary reason for the MRI? YES - Standard hip MRI NO - Depends on indication Which Protocol? Just write a good concise history and di ff erential diagnosis. Let the radiologist choose
28. Standard Hip MRI Three Planes • Wide fi eld of view of both hips/pelvis • Small fi eld of view centred on hip joint • Normal and fat saturated sequences • Intermediate weighted excellent for cartilage • Water sensitive good for bursitis and oedema Protocol Overview
29. Subgluteus Minimus Bursitis
30. Trochanteric Bursitis
31. Subgluteus Medius Bursitis
32. Trochanteric
 Bursitis Seen on MR Arthrogram
33. Post resurfacing
34. Ultrasound Cheap Point of Care Simultaneous guided intervention Operator skill Does not yield very archival images
35. Ultrasound Highly operator dependent Realtime examination Still images not easy to read
36. Lalala USS Transverse high resolution MSK USS
37. Recommended 
 Imaging Algorithm
38. Lateral Hip Pain 1. Plain Film X-ray (Pelvis) 2. Ultrasound lateral hip 
 with option of guided injection 3. MRI Hip 
 specialist request Radiological Investigation approach
39. How to request imaging
40. What makes a great request? • Build a relationship with a friendly MSK radiologist • Liberally communicate and discuss cases • Establish preferences: terminology, pathways, grading • Write concise, clear referrals • Always include differential diagnosis / clinical question • Let the radiologist choose the protocol Top tips to getting the most out of radiology
41. What makes a great request? IMAGING REQUEST: MRI Left Hip CLINICAL DETAILS: Left sided lateral hip pain radiating to buttock. Started 4-months ago after increase in running activities during lockdown. Limited response to rest, NSAIDs and physiotherapy. 
 Had CDH as child treated with osteotomy. Already had x-ray at Churchill Hospital. ? GTPS ? OA ? Impingement Top tips to getting the most out of radiology
42. Interventional Radiology
43. What can the radiologist do? • Ultrasound guided improves accuracy • Diagnostic vs therapeutic injections • Steroids vs non-steroid • Reversible phase of in fl ammation • Irreversible • Other interventions Interventions around the hip
44. USS guided injection Trochanteric Bursa
45. American Journal of Roentgenology 2011.197:W122-W127.
46. American Journal of Roentgenology 2011.197:W122-W127.
47. Many structures to target • Intricate anatomy • Many “Avoid” structures • Joints Hip, S IJ , symphysis • Bursae GT, Iliopsoas etc • Peritendinous CHO, gluteal • Lesions Around the pelvis
48. Swerve balls
49. Osteoarthritis I bet you it is
50. Ischiofemoral impingement
51. Ischiofemoral impingement Quadratus space
52. Common Hamstring tendinopathy
53. High Iliotibial Band Sprain
54. High Iliotibial Band Sprain
55. Torn Gluteal Tendons • History (Trauma, surgery) • Loss of function may be greater • Poor response to conservative • Radiology (MRI better than USS) How do I know it’s a tear? Arthroscopy Techniques, Vol 6, No 5 (October), 2017: pp e1523-e1527
56. Morel Lavallée Lesion STIR MRI High Resolution Panoramic USS
57. Morel Lavallée Lesion STIR MRI High Resolution Panoramic USS
58. Morel Lavallée Lesion STIR MRI High Resolution Panoramic USS
59. Key Points History, examination and knowledge of predispositions Physiotherapy, strengthening, conditioning Radiological approach X-ray > USS > MRI Establish working relationship with MSK radiologist Image guided intervention
60. Dr Daniel Fascia Consultant Musculoskeletal Radiologist @danfascia Thank You Questions & Answers