A key opinion leader in the field of orthopedics discusses how he or she would manage and treat a difficult case presentation.

How would you treat a 40-year-old woman with left groin pain?

In the evaluation of this 40-year-old woman with left hip pain, I would start with an extensive history and physical exam (Figures 1-4). Clearly, not all hip pain is the same. While it seems that the patient is reporting groin pain, I would want to discern whether the pain was intra-articular or extra-articular first.

Figure 1. A 40-year old woman presents with left groin pain for 1 year. She has had no help with rehabilitation and has a positive impingement sign. What would you do — arthoscope, periactebular osteotomy or injection?


Figure 2. Proton density-weighted MR imaging with fat supression is shown.


Figure 3. T2 coronal image is shown.


Figure 4. Coronal STIR MR image is shown.

Credit: Sankar WD

For example, if the patient reports painful snapping that is worse with external rotation maneuvers, psoas tendonitis may be responsible for her groin pain. If the pain does seem to be intra-articular, I would next want to determine whether the patient had instability-based symptoms vs. impingement-type symptoms. The two can often coexist. A positive impingement sign, to me, only indicates irritability of the joint — it doesn’t help me determine whether the patient is actually impinging or is just sore from another cause.

Wudbhav N. Sankar

A very careful assessment of range of motion is imperative to try and sort this out. Patients with true impingement will much more commonly have symptomatic restriction in motion, particularly internal rotation in the flexed position. Similarly, patients with impingement related pain would generally report it to be somewhat positional, while instability caused pain is more commonly activity associated.

Imaging

As far as the imaging work-up, the AP view of the pelvis suggests mild dysplasia on the left. A false profile view would be helpful to understand the anterior coverage of this hip, and a standing AP view may reveal even more evidence of instability. Dunn or frog lateral views would be helpful to look for cam morphologies.

The provided MR sequences suggest labral pathology, but it is important that the underlying etiology be determined as well as the current status of the articular cartilage before choosing the best treatment option. In my practice, dGEMRIC imaging in a patient of this age would provide important information on the amount of early osteoarthritis to allow appropriate counseling regarding the expected results of hip preservation surgery. Radial sequences and an assessment of femoral version are also included in my MR protocols to fully understand the three-dimensional morphology of this hip.

Treatment plan

Assuming that further work-up was consistent with the diagnosis of mild acetabular dysplasia, and that the patient had already attempted resting and/or activity modifications, I think it is reasonable to attempt an intra-articular injection. This can provide both diagnostic as well as a therapeutic effect. If her relief was transient and she still desired further intervention, one could consider a periacetabular osteotomy to address the dysplasia.

Although it is an involved procedure, a periacetabular osteotomy, unlike an arthroscopy, would allow full correction of her anatomic problem. Depending on her motion, a concomitant arthrotomy and osteoplasty may be necessary. Good results have been reported for this procedure in patients older than 40 years, but certainly the prognosis depends on the physiologic age of the patient and the health of the articular cartilage.

References:

Cunningham T. J Bone Joint Surg Am. 2006;88(7):1540-1548.

Millis MB. Clin Orthop Relat Res. 2009;doi:10.1007/s11999-009-0824-8.

Parvizi J. J Arthroplasty. 2009;doi:10.1016/j.arth.2009.05.021.

Wudbhav N. Sankar, MD, is director, Young Adult Hip Preservation Program, Children’s Hospital of Philadelphia, assistant professor of Orthopaedic Surgery, Perelman School of Medicine at the University of Pennsylvania.

Disclosure: Sankar receives royalties from Lippincott Williams & Wilkins, serves on the board of directors for the Pediatric Orthopaedic Society of North America.