Jenny Niedenfuehr, MPH, CHES®, CPH
Hip Abnormalities: Hip Dysplasia,
Impingement, and Labral Tears
Hip Dysplasia
According to the International Hip Dysplasia Institute, hip dysplasia, often called, developmental dysplasia of the hip (DDH), is an abnormality where the femur does not fit directly underneath the acetabulum. The sockets are simply characterized as shallow. Often times this condition is difficult to diagnose and needs a mix of different methods including x-rays, pelvis MRI, and hip CT Scans. If this condition is caught early on in infants, it can be resolved with the use of a Pavlik harness.
Some of the common symptoms associated hip dysplasia includes (Ellsworth et al,. 2021):
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Uneven leg lengths (Tamura et al,. 2019)
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Limping
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Pain in the hips
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Groin pain
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Public bone
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Lower back pain
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Si joint degeneration - see SI joint page (Okuzu et al., 2021)
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Pelvic hypertonicity
My bilateral PAOs under fluoroscopy on December 2021 - The one on the right is healed.
Periacetabular Osteotomy (PAO)
Periacetabular osteotomy is the most recommended surgical treatment for people with hip dysplasia and without arthritis. With most dysplasia issues, if the abnormalities are caught before arthritis develops, the hips can be treated with strengthening exercises through physical therapy surrounding the glutes, abdomen, and back, and/or periacetabular osteotomy surgery. Generally, physical therapy is the recommended course of action until pain symptoms occur. Cortisone injections don’t always guarantee painless hips. Alternatively, hip replacement remains as an option for arthritic joints, but difficulties can arise from them (Gala et al., 2016).
During the periacetabular osteotomy surgery (PAO) procedure, the acetabulum is reshaped over the femoral head (ball) with different cuts, and is twisted and realigned with screws. This may sound very scary, but the surgery comes with very little risks and you are guaranteed a decent outcome with a good surgeon if you follow their instructions. The duration of the surgery may take up to four hours, but you are actually under anesthesia for six to eight hours. If an individual has a very skilled surgeon who completes over 50 PAO’s a year, the actual surgery itself is about 1.5 hrs of active work. Recovery takes about a year per hip, so it is not a small procedure. However, with a skilled surgeon, you are guaranteed to have a great outcome. I will be posting several blog posts on this surgery throughout with good tips and how to prepare for it as it's so major and you will definitely need some help around the house for a few weeks until you are mobile.
Sometimes, athletes and dancers will have PAO surgery and the surgeon will not completely eliminate the dysplasia so they can maintain their mobility. Oftentimes, dysplasia will not cause pain until people reach their mid-20s and most people won’t even know they had it until the pain is severe. Dysplasia can be responsible for causing femoral acetabular impingement and labral tears, which I will discuss in this next section. That being said, if you think you have hip abnormalities or sense catching, clicking, or locking, please get your hips checked as this issue can lead to early-onset arthritis.
Hip Impingement: Cam, Pincer
Femoracetabular impingement, also known as FAI, often time presents itself with hip pain and has the potential lead to hip osteoarthritis over time if its not managed. Arthroscopic osteoplasty has been shown as the best solution to correct these malformations (Crawford et al., 2005). During the arthroscopy, the surgeon will insert a tube with a fiber-optic video camera through three small incisions where they will be able to inspect the abnormalities much closer. Many athletes are known to have FAI. Jerking, twisting, and turning are common movements that lead to FAI and even labral tears. FAI is divided into two type called cam and pincer, and some people are known to have more than two types of impingement (Bech & Haverkamp, 2018).
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Cam impingement consists of femoral head malformations that can actually shear the labrum and cause tearing. 60% of patients with this impingement can be treated without surgery
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Pincer impingement is a common formation in athletic people. With this condition, the acetabulum covers the majority of the femur.
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Ischiofemoral impingement is the rarest type of impingement and occurs when soft tissues are trapped and crushed between a part of the femur and ischium (sit bone). This is not characterized as FAI, but is often mistaken as being included in this category.
Labral Tears/ Labrum Tears
The hip labrum is a ring of connective tissue that is attached to the rim of the hip socket. Oftentimes, hip impingement and dysplasia can cause labral tears, which can cause worsening pain and symptoms. Luckily, there are surgeons that are able to perform athroscopy to correct the tearing and also do a periacetabular osteotomy in the same day. Labral tears actually do not exist without some type of abnormality or malformation (Hartig-Andreasen et al., 2013). Most interestingly, there have been instances where labral tears actually are not present and vice versa despite them appearing or not appearing on an MRI for both shoulders and hips.
How were my hips diagnosed?
Multiple imaging techniques are absolutely necessary to confirm that dysplasia is present.
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Physical evaluation
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FADIR evaluation
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Hip CT Scans - Feb 20, 2021
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Pelvis MRI - Feb 20, 2021
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45 and 90 degree dunn x-rays, Feb 22, 2021
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MRI arthrogram of right hip with contrast - November 10, 2021 - before my second surgery
How can these affect your pelvic floor?
More research is needed to truly understand the relationships between the hips and the pelvic floor. In the last year, more providers are becoming aware of the relationship between the hips, sexual dysfunction, vulvar and penile pain, but orthopedic doctors are seemingly lacking on pelvic pain teams. Only one study has demonstrated an exact decrease in vulvodynia, vulvar pain, and pelvic floor dysfunction with the correction of the FAI impingement through arthroscopy (Coady et al., 2015). Coady et al. (2015) performed a case series with patients with both vulvodynia/clitorodynia and FAI. 3-5 years post-op, six patients mentioned improvement in their vulvodynia. The other twenty did not experience much improvement, but they were older than 30 years of age. Alternatively, local anesthetic and cortisone injections are commonly used to rule out specific anatomical sites and provide a linkage between sexual dysfunction and hips, and diagnosis of FAI, but they are not always successful (Khan et al., 2015).
Tamaki et al. (2014) conducted a prospective study to evaluate urinary symptoms pre and post-op after total hip arthroplasty (hip replacement). 43% of their 81 patients experienced urinary incontinence pre-surgery, but 3 months after the operation, 64% mentioned their incontinence had improved. However, 32% reported they had unchanged symptoms and 4% reported they had worse symptoms. The authors suggested that there is a relationship between pelvic floor and hip functioning related to urinary incontinence.
Furthermore, Foster et al. (2021) conducted a study with 21 pairs (42 women) to assess hip external rotator and abductor strength, and equivalent pelvic floor strength. The authors also highlighted that hip strengthening may be beneficial to aid patients with urinary frequency. The patients with urinary frequency and predominant urinary tract infections had weak hip muscles (external rotators and abductor muscles), but had similar pelvic floor strength and endurance to those without the urinary issues.
Recently, Thummal et al. (2022) conducted a study to assess whether surgery affected pelvic tilt in patients with osteoarthritis. The results revealed that there was a decease in pelvic tilt after patients with osteoarthritis had surgery (periacetabular osteotomy and arthroscopy). The authors suggest that surgery should be considered to best "optimize pelvic orientation."
Hip Strengthening
Recent research has suggested that patients with undiscovered abnormalities, especially connective-tissue disorders, hip abnormalities, and lax joints, may improve mostly by strengthening and not relaxing and stretching the surrounding muscles. This is a discrepancy between the treatments that are suggested in pelvic floor PT and should be used with caution. Most people may not even realize they have hip abnormalities as gynecology and urology are often a first port of entry for many patients when experiencing sexual pain. Overstretching and manually working on a weak muscles in spasm can contribute to further exacerbation and pain symptoms (Laferrier et al., 2018).
In a study by Aoyama et al. (2022), patients with femoral acetabular impingement (FAI) demonstrated improvement in their hips with the implementation of trunk stabilization exercises. For patients with developmental hip dysplasia, improvement in pain and walking ability has been revealed to occur after 3 months of progressive hip adductor strengthening, and in another study, 8 weeks of resistance training improved pain levels and function (Kuroda et al. 2013; Mortensen et al.,2018).
What are the angles that should be considered
when evaluating a patient for hip dysplasia?
Generally, the hip specialists order a mix of imaging tests to understand the full picture at hand and perform a physical evaluation. With the improved understanding of hip diseases and structure, CT scans, pelvis MRIs, and X-rays are helpful in confirming hip abnormalities (Wylie et al., 2017).
Lateral Center Edge Angle (LCEA):
Determines how well the acetabulum (hip socket) covers the head of the femur (ball of the hip joint).
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25-35 degrees = normal
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Greater than 39 = over coverage sometimes associated with pincer impingement
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Less than 25 degree = shallow hip sockets also known as hip dysplasia
Alpha Angle:
Determines how much the femoral head varies from the normal, spherical shape
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If the angle is greater than 55 degrees, it can be seen in impingement and cam morphology.
Tonnis Angle: Measures the slope of the hip socket.
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0-10= normal
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Less than 0 degrees: Seen with FAI
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Greater than ten degrees is seen with dysplasia
The Acetabular Index
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This index is seen with hip dysplasia and can cause stress and pressure on the joint
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If the angle is greater than 42 degrees, this is commonly associated with hip dysplasia
Femoral Neck – Shaft Angle
Image from: https://www.hss.edu/conditions_femoral-osteotomy-overview.asp
This measurement is used to diagnose hip dysplasia, FAI, Legg Calves – Perthes Disease, osteogenesis imperfecta and other fractures.
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125-135 = normal
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Less than 25 degrees = “coxa vara” (“varus”)
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Greater than 135 degrees = “coxa valga” (“valgus”)
Femoral Version:
Lastly, femoral version shows how much twist there is in the femur bone.
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10-20 degrees = Normal
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Greater than 20 degrees = increased femoral anteversion (femoral neck leans forward)
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Less than 10 degrees = femoral retroversion (femoral neck leans backwards)
References
Aoyama, M., Ohnishi, Y., Utsunomiya, H., Kanezaki, S., Takeuchi, H., Watanuki, M., Matsuda, D. K., &
Uchida, S. (2019). A Prospective, Randomized, Controlled Trial Comparing Conservative Treatment With Trunk Stabilization Exercise to Standard Hip Muscle Exercise for Treating Femoroacetabular Impingement: A Pilot Study. Clinical Journal of Sport medicine: Official Journal of the Canadian Academy of Sport Medicine, 29(4), 267–275. https://doi.org/10.1097/JSM.0000000000000516
Bech, N. H., & Haverkamp, D. (2018). Impingement around the hip: beyond cam and pincer. EFORT open reviews, 3(2), 30–38. https://doi.org/10.1302/2058-5241.3.160068
Coady, D., Futterman, S., Harris, D., & Coleman, S. H. (2015). Vulvodynia and Concomitant Femoro-Acetabular Impingement: Long-Term Follow-up After Hip Arthroscopy. Journal of lower genital tract disease, 19(3), 253–256. https://doi.org/10.1097/LGT.0000000000000108
Chiamil, S. M., & Abarca, C. A. (2016). Imaging of the hip: a systematic approach to the young adult hip. Muscles, ligaments and tendons journal, 6(3), 265–280. https://doi.org/10.11138/mltj/2016.6.3.265
Ellsworth, B. K., Sink, E. L., & Doyle, S. M. (2021). Adolescent hip dysplasia: what are the symptoms and how to diagnose it. Current opinion in pediatrics, 33(1), 65–73. https://doi.org/10.1097/MOP.0000000000000969
Foster, S. N., Spitznagle, T. M., Tuttle, L. J., Sutcliffe, S., Steger-May, K., Lowder, J. L., Meister, M. R., Ghetti, C., Wang, J., Mueller, M. J., & Harris-Hayes, M. (2021). Hip and Pelvic Floor Muscle Strength in Women with and without Urgency and Frequency Predominant Lower Urinary Tract Symptoms. Journal of women's health physical therapy, 45(3), 126–134. https://doi.org/10.1097/jwh.0000000000000209
Gala, L., Clohisy, J. C., & Beaulé, P. E. (2016). Hip Dysplasia in the Young Adult. The Journal of bone and joint surgery. American volume, 98(1), 63–73. https://doi.org/10.2106/JBJS.O.00109
Hartig-Andreasen, C., Søballe, K., & Troelsen, A. (2013). The role of the acetabular labrum in hip dysplasia. A literature overview. Acta orthopaedica, 84(1), 60–64. https://doi.org/10.3109/17453674.2013.765626
Khan, W., Khan, M., Alradwan, H., Williams, R., Simunovic, N., & Ayeni, O. R. (2015). Utility of Intra-articular Hip Injections for Femoroacetabular Impingement: A Systematic Review. Orthopaedic journal of sports medicine, 3(9), 2325967115601030. https://doi.org/10.1177/2325967115601030
Kuroda, D., et al., Dynamic hip stability, strength and pain before and after hip abductor
strengthening exercises for patients with dysplastic hips. Isokinetics and Exercise Science, 2013.21: p. 95-100
Laferrier, J., Muldowney, K., & Muldowney, K. (2018). A Novel Exercise Protocol for Individuals with Ehlers Danlos Syndrome: A Case Report. Journal of Novel Physiotherapies, 08. https://doi.org/10.4172/2165-7025.1000382
Mortensen, L., Schultz, J., Elsner, A., Jakobsen, S. S., Søballe, K., Jacobsen, J. S., Kierkegaard, S., Dalgas, U., & Mechlenburg, I. (2018). Progressive resistance training in patients with hip dysplasia: A feasibility study. Journal of Rehabilitation Medicine, 50(8), 751–758. https://doi.org/10.2340/16501977-2371
Okuzu, Y., Goto, K., Shimizu, Y., Kawai, T., Kuroda, Y., & Matsuda, S. (2021). Sacroiliac joint degeneration is common in patients with end-stage hip osteoarthritis secondary to unilateral developmental dysplasia of the hip: Factors associated with its severity and laterality. Journal of orthopaedic science: Official journal of the Japanese Orthopaedic Association, 26(1), 135–140. https://doi.org/10.1016/j.jos.2020.02.005
Tamaki, T., Oinuma, K., Shiratsuchi, H., Akita, K., & Iida, S. (2014). Hip dysfunction-related urinary incontinence: a prospective analysis of 189 female patients undergoing total hip arthroplasty. International journal of urology : official journal of the Japanese Urological Association, 21(7), 729–731. https://doi.org/10.1111/iju.12404
Tamura, K., Takao, M., Hamada, H., Ando, W., Sakai, T., & Sugano, N. (2019). Femoral morphology asymmetry in hip dysplasia makes radiological leg length measurement inaccurate. The Bone & Joint journal, 101-B(3), 297–302. https://doi.org/10.1302/0301-620X.101B3.BJJ-2018-0965.R1
Thummala, A. R., Xi, Y., Middleton, E., Kohli, A., Chhabra, A., & Wells, J. (2022). Does surgery change pelvic tilt? : an investigation in patients with osteoarthritis of the hip, dysplasia, and femoroacetabular impingement. The bone & joint journal, 104-B(9), 1025–1031. https://doi.org/10.1302/0301-620X.104B9.BJJ-2022-0095.R1
Wylie, J. D., Kapron, A. L., Peters, C. L., Aoki, S. K., & Maak, T. G. (2017). Relationship Between the Lateral Center-Edge Angle and 3-Dimensional Acetabular Coverage. Orthopaedic journal of sports medicine, 5(4), 2325967117700589. https://doi.org/10.1177/2325967117700589

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