I've updated this post on my thoughts behind why Adult Hip Dysplasia seems so hard to diagnose. Despite it being a relatively common condition
in babies and young children, and it only takes an x-ray to identify it, an adult with hip problems can
potentially be sent around the houses until they reach a diagnosis, and
this can take many years (Nunley et al, 2011).
Below are some of my thoughts as to why this seems to happen:
Subtle early symptoms
Below are some of my thoughts as to why this seems to happen:
Subtle early symptoms
The
early symptoms accompanying dysplasia can seem quite mild, presenting as an insiduous onset recurring groin strain that by all accounts appears muscular in origin (Pun, 2016). Clinicians also refer to what they call the "C-sign," when a patient
cups their fingers around the lateral part of the hip to indicate
something going on deep inside. A patient might find this hard to
describe or point to.
Symptoms related to activity
The
early typical symptom pattern of this hip pathology is
most commonly noticed during sport or activity (Nunley et al, 2011), so
the symptoms might disappear when a patient takes a break from their
sport. With recurrance of the pain, they might decide to just stop
altogether. This could work fine for a while, or even a few years
before the symptoms increase anyway.
Vague history
A
young adult who has been treated for DDH as an infant may not put 2 and
2 together that this is related to their current hip pain. Some of us
are told that the "clicky hip" we had as a baby was successfully treated
and 'fixed' with no need for follow-up. A patient will also be relying
on what their mother/care-giver has told them about it. I wonder if
the right questions are asked and clarified about this when a patient presents with
hip or groin pain.
Hip Dysplasia in adults??
Some
health practitioners might not be aware that DDH can occur in
adulthood without an infant diagnosis. More recent literature speaks of adolescent-onset dysplasia as well as residual childhood dysplasia presenting in adulthood. It can reoccur even if treated successfully at birth. (Pun, 2016).
The mix-up with impingement
The mix-up with impingement
Hip Dysplasia presents with very similar
clinical signs and symptoms to Femoroacetabular Impingement, and these
are hard to differentiate (Nunley et al, 2011). For example, in both DDH and FAI, pain will
occur when flexing and internally rotating the hip. However, with an
impinged hip this is due to the femoral neck hitting against the
acetabulum, whereas in DDH this is due to it hitting a sore labrum. It
is not unheard of for Dysplasia to be misdiagnosed as Impingement. A clearer diagnostic picture can be formed when subjective and clinical findings are backed up with x-rays interpreted by a hip specialist for a full diagnostic picture.
Not feeling the need to diagnose
If
the symptoms present seem concurrent with a soft tissue injury, and
physiotherapy and strengthening techniques are working for the time
being, then a clinician might not feel the need to find a definitive
diagnosis.
Awareness of other options
Not all health professionals are aware that Pelvic Osteotomy such as PAO or TPO surgery exists for the treatment of adult hip dysplasia. This is a surgery which re-shapes the acetabulum in order to delay OA in a dysplastic hip and therefore delay hip replacement until a later age, but is more likely to be successful before OA has developed in the joint.
Awareness of other options
Not all health professionals are aware that Pelvic Osteotomy such as PAO or TPO surgery exists for the treatment of adult hip dysplasia. This is a surgery which re-shapes the acetabulum in order to delay OA in a dysplastic hip and therefore delay hip replacement until a later age, but is more likely to be successful before OA has developed in the joint.
Not knowing when to refer
There can be difficulty knowing at what point a
patient with hip or labral symptoms should be referred on to a specialist hip consultant. Groh (2009) suggests that
there should be 12 weeks of physio input and if this hasn't worked then
refer on.
If you think that a patient has an underlying abnormal hip pathology such as Dysplasia or Impingement, or have a strong suspicion they do based on your subjective and clinical findings, then the referral should happen promptly. For example, they might know that they've had it from birth, or they might have had an x-ray and diagnosis from a non-specialist in orthopaedics. Obviously you don't need to send them off in an ambulance with the sirens wailing, but a timely definitive diagnosis is pretty important (for more on this, see my related post: Why the Rush?)
If you think that a patient has an underlying abnormal hip pathology such as Dysplasia or Impingement, or have a strong suspicion they do based on your subjective and clinical findings, then the referral should happen promptly. For example, they might know that they've had it from birth, or they might have had an x-ray and diagnosis from a non-specialist in orthopaedics. Obviously you don't need to send them off in an ambulance with the sirens wailing, but a timely definitive diagnosis is pretty important (for more on this, see my related post: Why the Rush?)
Lack of access to an experienced consultant in hip dysplasia
A
consultant who specialises in young adult hip pathologies and who
treats a large volume of cases is worth their weight in gold, but they
are few and far between and dotted around the country. Those who aren't
as specialised or who don't treat as many cases may have a harder time
interpreting the findings from x-rays and clinical presentation (Malviya et al, 2016), or may
be reluctant to operate on hips with less severe dysplasia due to
uncertainty of outcomes. There are stories of dysplasia just not being
picked up by orthopaedics even with an x-ray. These factors may cause
confusion for patients and their referring clinicians.
With
all the above being said, it is important to realise that there are
positive stories also, of symptoms being recognised, referrals being
made to the right clinicians, and favourable outcomes from surgeries.
There are undoubtedly many highly skilled and astute clinicians out
there. I'm sure I am one of many hipsters who is, at times, guilty of
throwing my hands up in the air and exclaiming "Aaah, nobody knows
anything about this condition!" And whilst that is obviously said out
of exasperation, the above points need to be taken note of.
See also: Why the Rush?
Info taken from:
Malviya, A., Raza, A. & Witt, J. D. (2016) Reliability in the diagnosis of femoroacetabular impingement and dysplasia among hip surgeons: role of surgeon volume and experience, Hip International, Vol. 26 (3)
Nunley, R. M., Prather, H., Hunt, D., Schoenecker, P. L. & Clohisy, J. C. (2011) Clinical Presentation of Symptomatic Acetabular Dysplasia in Skeletally Mature Patients, The Journal of Bone & Joint Surgery. 93-A (2)
Pun, S. (2016) Hip Dysplasia in the Young Adult caused by residual childhood & adolescent-onset dysplasia, Current Rev Musculoskeletal Medicine, Vol. 9 (4)
West, S., & Witt, J. (2011) Bilateral Developmental Dysplasia of the Hips, British Medical Journal. 342 doi doi: http://dx.doi.org/10.1136/bmj.d2152
