In my days of leisure I have been browsing resources to see what I can learn about persitant pain conditions, particularly the evidence surrounding the management of back pain (CSP, 2016). I've been thinking about these recently compared with my experience and what the evidence says about hip conditions. Here are my thoughts related to the following:
Pain & activity
Abnormal hip pathology that adversely effects the labrum can be exaccerbated with certain types of activity. The labrum contains a lot of nociceptive nerve endings and is therefore highly sensitive (Haversath et al, 2013). It is very easily irritable when injured and takes a long time to settle (Burnett et al, 2008). Symptoms beginning in DDH are unlikely to get better overall, and advice is usually to manage labral tears and hip pain like this by refraining from sporting activities which aggravate (O'Hara, 2017 & Groh, 2009).
Pain & activity
Abnormal hip pathology that adversely effects the labrum can be exaccerbated with certain types of activity. The labrum contains a lot of nociceptive nerve endings and is therefore highly sensitive (Haversath et al, 2013). It is very easily irritable when injured and takes a long time to settle (Burnett et al, 2008). Symptoms beginning in DDH are unlikely to get better overall, and advice is usually to manage labral tears and hip pain like this by refraining from sporting activities which aggravate (O'Hara, 2017 & Groh, 2009).
My experience of trying to find ways of exercising with a dysplastic hip
has, at points, been extremely difficult, particularly at times when
the pain and function of the joint has deteriorated. Impact activity is
definitely a no-no. Managing symptoms throughout the day in order to
still be able to stand up long enough to cook a meal in the evenings has
been a challenge. At one point I found most physio and Pilates
exercises were only exacerbating symptoms and I had to abandon them and
just do a small amount of swimming (although at other times even this was flaring up symptoms). Don't get me wrong, I am not advocating inactivity! Just highlighting the challenge faced by someone in this situation - it's frustrating for someone like me who enjoys staying active!
In terms of daily activities & functions, specialists say that some patients with hip pathologies find themselves subconsiously gradually reducing certain movements over a number of years due to the discomfort caused. They may stop impact sports, then stop walking certain distances, then certain functional movements like pivoting and putting on shoes become more difficult. By the time they receive an accurate diagnosis they have been living with a somewhat mild yet chronic disability for 10 or so years, and are deconditioned and maybe even a little overweight, which makes recovery from surgery harder (O'Hara, 2017). For others the decline is much more dramatic and can take only a few months to become debiliating (West et al, 2011).
Pain and *Damage* (shh, don't say it too loud!)
Literature about hip conditions indicates that when symptoms like locking, catching and giving way begin in a dysplasic or impinged hip in adulthood, this is a sign that the labrum is beginning to become injured by the abnormal loading of the hip joint (West et al, 2011). A damaged or torn acetabular labrum is considered to be the first step along the road to osteo-arthritis (McCarthy et al, 2001).
There are lots of instances where pain doesn't necessarily equate to damage occurring in the body, and social and psychological factors can have a huge impact on somebody's experience of pain (and vice-versa). In light of this I believe it's important to choose words carefully when explaining things to patients, because a faulty understanding about pain, particularly in some chronic conditions, can lead to fear of movement itself and thus increase disability. I wonder at times if there are ways of describing a pathology without instigating more worry for a patient?
There's a certain amount of psychological adjustment to receiving a diagnosis of DDH in adulthood, and sometimes big life decisions to make around having major surgery, how to fit things in around work and when to start a family. These decisions are hard to weigh up if things aren't explained clearly. A patient needs to understand that they may have to modify their activities and lifestyle in the long run to keep the hip in the best condition and delay OA. I am only an unqualified physio student with little experience in practice yet, but from others' stories and what I've read in the literature OA seems to develop very quickly in a dysplastic hip (Wyles et al, 2017). For some, the understanding of the condition doesn't sink in or impact activities are maintained, and they get a nasty shock when they discover hip OA is present in their 20s or 30s and their options are then reduced to THR only.
Personally, I found it took a long time for it to 'click' that DDH is degenerative. This wasn't helped by misinformation I was given and attempts by health professionals to be optimistic without fully explaining the condition to me. I really wish someone had properly explained it all to me earlier on. It would have made the process of adjustment a little less stressful.
When assessing an adult with hip or groin pain, evidence that some hip pathologies lead to the early development of OA suggests that it is important to be working from an accurate diagnosis of what is causing the pain (Wyles et al, 2017). Evidence seems to state that conservative treament should be attempted at first for roughly 3 months (Groh et al, 2009), but if they are not improving, or there is anything noted in the history as potentially pointing towards such a structural abnormality, an x-ray should be requested. Hip osteotomies, which are designed to delay the need for a THR, are known to be much more successful before the development of OA in the joint (Coobs et al, 2015).
Is imaging needed?
Unnecessary imaging and over-investigations of pain complaints can be unhelpful in some cases and cause added worry for a patient (Webster et al, 2013). However, a pelvis x-ray interpreted by a clinician who specialises
in young adult hips can accurately reveal or rule out
Dysplasia or Impingement should either of these be suspected (Malviya et al, 2016). If FAI or DDH are shown, then MRI scans are sometimes used later
on to help visualise the quality of the joint to help decide surgery
options.
I've heard it said that referral requests need to be worded specifically, and that sometimes an x-ray can come back as 'normal' meaning 'no arthritic change' rather than stating whether the morphology of the joint is abnormal. I've also heard it said that both AP and lateral x-rays are helpful for diagnosis. However, this is not from my own professional experience, just what I've heard from others experienced in the field.
I've heard it said that referral requests need to be worded specifically, and that sometimes an x-ray can come back as 'normal' meaning 'no arthritic change' rather than stating whether the morphology of the joint is abnormal. I've also heard it said that both AP and lateral x-rays are helpful for diagnosis. However, this is not from my own professional experience, just what I've heard from others experienced in the field.
Info taken from:
Burnett, R. S., Della Rocca, G. J., Prather, H., Curry, M., Maloney, W. J. & Clohisy, J. C. (2008), Clinical presentation of patients with tears of the acetabular labrum, The Journal of Bone & Joint Surgery 88 (7)
Coobs, B. R., Xiong, A. & Clohisy, J. C. (2015) Contemporary Concepts in the Young Adult Hip Patient: Periacetabular Osteotomy for Hip Dysplasia, The Journal of Arthroplasty. Vol. 30
CSP (2016) Debunking Myths about Back Pain. Retrieved from: http://www.csp.org.uk/frontline/article/debunking-myths-about-back-pain
CSP (2016) Back Pain Myth Busters. Retreived from http://www.csp.org.uk/your-health/healthy-living/public-information-leaflets/back-pain-myth-busters
Groh, M. M. & Herrera, J. (2009), A comprehensive review of hip labral tears, Current Reviews in Musculoskeletal Medicine. 2 (2). doi: 10.1007/s12178-009-9052-9
Haversath M., Hanke J., Landgraeber S., Herten M., Zilkens C., Krauspe R., Jäger M. (2013), The distribution of nociceptive innervation in the painful hip, The Bone & Joint Journal. 95-B (6) doi: 10.1302/0301-620X.95B6.30262
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)
McCarthy, J. C., Noble, P. C., Schuck, M. R., Wright, J. & Lee, J. (2001) The Otto E. Aufranc Award: The role of labral lesions to development of early degenerative hip disease, Clinical Orthopaedics & Related Research. 393
O'Hara, J. (2017) 'Pelvic Osteotomies,' The Birmingham Hip Clinic. Retrieved from: http://birmingham-hip-clinic.com/HipTreatments/PelvicOseteotomies
Webster, B. S., Bauer, A. Z., Choi, Y. S., Cifuentes, M. & Pransky, G. S. (2013) Iatrogenic Consequences of Early Magnetic Resonance Imaging in Acute, Work-Related, Disabling Low Back Pain, Spine, 38 (22). 1939 – 1946
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
Wyles, C. C., Heidenreich, M. J., Jeng, J., Larson, D. R., Trousdale, R. T. & Sierra, R. J. (2017) The John Charnley Award: Redefining the Natural History of Osteoarthritis in Patients with Hip Dysplasia and Impingement, Clinical Orthopaedics & Related Research. 475. 336 - 350.
