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!