Hip Osteoarthritis and the Piriformis
Syndrome How can we reliably distinguish these entities from
lumbar disease?
Alan L. Saperstein MD
Affiliate Assistant Professor of Clinical Biomedical Science
Florida Atlantic University Charles E. Schmidt School of
Medicine
Team Orthopaedic Surgeon Florida Atlantic University
Team Orthopaedic Surgeon Lynn University
Partner, Boca Raton Orthopaedics and Sports Medicine
Hip pathology which may mimic
spinal pathology
● Hip osteoarthritis
● Labral tears and femoracetabular impingement
● Trochanteric bursitis/gluteus medius tendinopathy
● Piriformis syndrome
Distinguishing Hip from Lumbar Spine
Pathology
History
● Location
● Radiation below knee
● Exacerbating Activities
● Associated Symptoms
– LBP
– Parasthesia/numbness
Distinguishing Hip from Lumbar Spine
Pathology
Physical Examination
● Gait analysis
● Trandelenberg sign
Distinguishing Hip from Lumbar Spine
Pathology
Physical Examination
● Tenderness
– Trochanteric bursa
– Gluteus medius
– Piriformis muscle/tendon
● Range of motion
– Limitation
– Pain on passive motion (FADIR test)
– Pain on resisted motion
Distinguishing Hip from Lumbar Spine
Pathology
Diagnostic Testing
● Hip xray
● MRI hip/lumbar spine
● CT hip
● Electrodiagnositic testing (+/- provacative
positioning)
Distinguishing Hip from Lumbar Spine
Pathology
Selective Injection
● Hip joint
● Trochanteric bursa
● Piriformis muscle (U/S guidance)
Piriformis Syndrome
Diagnostic Criteria (Miller, 2012)
● Buttock/posterior thigh pain worsened by sitting,
stair climbing or leg crossing
● Tenderness sciatic notch
● No axonal loss on electrodiagnostic testing
● No other imaging findings to explain sciatica
● >60% symptom reduction with piriformis injection
Treatment of Hip Pathology
Osteoarthritis
● Activity modification
● Ambulatory aides
● NSAIDS, pain meds
● PT
● Intraarticular corticosteroid injection
● Total Hip Arthroplasty
Treatment of Hip Pathology
Labral Tears/Impingement
● Physical therapy
● NSAIDS
● Intraarticular corticosteroid injection
● Arthroscopic labral debridement/repair, osteoplasty
Treatment of Hip Pathology
Labral Tears/Impingement
● Physical therapy
● NSAIDS
● Intraarticular corticosteroid injection
● Arthroscopic labral debridement/repair, osteoplasty
Treatment of Hip Pathology
Trochanteric bursitis/gluteus medius
tendonopathy
● ITB stretch
● NSAIDS and pain medication
● Trochanteric bursal injection
● Open/arthroscopic bursectomy +/-gluteus medius
tendon repair
Treatment of Hip Pathology
Piriformis Syndrome
● Rest
● NSAIDS
● PT (internal rotation stretch)
● Piriformis muscle injection (corticosteroid,
botulinum toxin)
● Caudal epidural injection
● Piriformis release with sciatic neurolysis
THANK YOU!
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