Case Study Reflection
For the purpose of this real life case study report I will refer to the patient as Dennis although he has fully consented, I wanted to keep him anonymous.
Dennis originally came to see me in clinic in April ‘21, with an ongoing issue with his left hip. At 31 years of age, over 6 ft, well built and having played rugby his whole life, Dennis came to see me about his ongoing hip issue, (remember I really am a one a trick pony!). This was a similar situation to many patients that I see each week within private practice, with patients arriving with consultant letters, scans, x-rays, with most patients coming to me to see if they can avoid surgery or not.
I’ll paint the picture of Dennis in a bit of a clearer light to set the scene…
- Left hip pain (anterior and buttock occasionally) – some similar right hip pain too. Ongoing for 2 years prior to seeing me.
- Stiff and sore into flexion and adduction
- Occasional episodes of flare ups, causing him to limp
- Impacting ALL exercise levels due to pain + anxiety of making it worse long term
- Finds sitting and prolonged walking provocative
- No red flags, no other PMH of note
- No LBP
- Clinically, nothing jumping out other than what I would have expected… a stiffer hip, not to the point that I would suspect OA changes but definitely a reduction in rotational axis & equally provocative when assessing too. Areas of reduced conditioning and strength in the normal areas that you would expect for an FAIs hip….and that’s where my mindset was at that point. FAIS.
None of my assessment to that point had led me down any other route to suspect anything else and I was fairly confident we were able to navigate around the hip and pelvis during the assessment to identify that joint related assessment findings were certainly where symptoms were most provocative.
Dennis, like I said, much like many of my patients, had arrived with some insight as to what he suspected was going on based on some imaging that he had and also his own research and reading around young adult hip pain. I love that. Not the imaging bit, but the fact that a vast amount of my patients care enough about their health that they properly research around a topic, not just Dr Google. As it stood we were both of the mindset that this could be an FAIs related issue. To date Dennis had a pelvic xray in 2019 but this was unremarkable. However I wouldn’t say that’s uncommon for some FAIs features to not be identified or missed on reports. I didn’t have the images though. Soon after we met, Dennis was already booked for an MRA in the right hip, which showed an increased alpha angle and labral tear. Ok, that kinds of fits what I was thinking, it’s not a given even still that either of those things are the problem, but the shoe fits.
It's time for rehab anyway, irrespective of what the images were telling us. In front of me I had a young patient who I was determined to get back to a level of sport and exercise that he desired. Unfortunately much like everything, COVID put a right spanner in the works and that impeded upon our rehab journey. A complete shitter. Nonetheless we stuck it out sporadically, we progressed and regressed where we needed to and waited to see how things transpired. Unfortunately for one reason or another, the symptoms had not resolved completely. It’s fair to say the symptoms were not debilitating Dennis to the point of his QoL was significantly impaired, but we weren’t at the level we wanted to be. It was a few months back from today’s date that Dennis had referred to a different consultant to one he had previously seen just to get some more insight into what was going on. It was during this consultation that he was advised to have a 3D motion analysis CT for some further investigations into his hip and to see if something may have been missed.
Three-dimensional (3D) motion analysis is a method based on biomechanical models that use external skin markers to define a local coordinate system to each skeletal segment which enables calculations of joint kinematics in all three planes (Wu et al., 1995). Computed tomography (CT) provides additional information, compared to radiography, including 3D information of the joint (Naili et al., 2021). FAIs is a 3D condition that is typically evaluated via 2D imaging techniques and measurements. However, studies have shown that these measurements have varying degrees of accuracy based on both image quality and operator interpretation, (Hanson et al 2015).
I wasn’t really sure what to expect. Clinically nothing was jumping out for me to suspect anything different to what I’d thought. There were morphological features of FAIs that we’d seen on imaging previously, but what was the hindrance to progress?
To my surprise I had a message from Dennis to say that his results came back and he had hip dysplasia! It took me by surprise, mainly because I can count on one hand the number of male dysplasia patients I’ve seen in recent years, but equally the clinical picture really didn’t fit. He wasn’t a young caucasian female (a common patient group Gala et al., 2016), nor was he a ballet dancer! To add to that, the hip didn’t have an excessive rotational axis or signs of instability.
On reading the scan results it noted two things:
- CEA 19 degrees
- Anterior coverage 29 degrees.
Acetabular coverage is an important component in the evaluation of hip dysplasia and FAIS. Acetabular coverage has been traditionally based on anteroposterior (AP) and lateral radiographs by calculating the LCEA (Fritz et al., 2019) Wiberg originally defined values of 25 to 40 as normal in adults; values of 20 to 25 as indeterminate; angles <20 as dysplastic; and measurements >40 as representing over coverage, such as in pincer-type FAI. Dandachli et al (2008) has also cited that anything below the threshold of 30 degrees for anterior covered would be classified as dysplasia.
Having had a chance to catch up with Dennis for the first time in months after these results, it was really sobering for me and made me realise just how difficult it is to pick up these hip related morphological changes that can lead to young adult hip pain. Luckily Dennis’ isn’t sufficient enough to warrant a surgical intervention and we’ve changed our rehab approach slightly with this in mind. However he has more of the clarity that he was after and that too can be extremely empowering. Some patients aren’t so lucky. Not everyone has access to 3D CT, private physio or private consultants. We had got to this stage, albeit with obstacles along the way, after 10 months of physio input, though now Dennis had had symptoms for nearly 3.5 years. With an average time to diagnosis for hip dysplasia being cited at 5 years, you can see why.
Hip dysplasia can be a really problematic and debilitating condition and when missed and untreated can lead to hip OA. It’s ALWAYS on my radar, but on reflection of this case I will definitely keep it on my radar far more for my male patients now going forward. For those of you who rarely/haven’t seen a dysplasia patient, read about it, research it and just be mindful of it within your clinical differentials. The sooner we bring down that average time to diagnosis hopefully more patients will get the answers and interventions that they need.
Apologies if my references are not done correctly, but I’m not at Uni, and this is my website and now I can do what the hell I want! :D
Dandachli, W., Kannan, V., Richards, R., Shah, Z., Hall-Craggs, M., Witt, J., 2008. Analysis of cover of the
femoral head in normal and dysplastic hips: New CT-based technique. J Bone Joint Surg Br 90-B, 1428–
Naili, J. E., Stålman, A., Valentin, A., Skorpil, M., & Weidenhielm, L. (2021). Hip joint range of motion is restricted by pain rather than mechanical impingement in individuals with femoroacetabular impingement syndrome. Archives of Orthopaedic and Trauma Surgery, 1-10.
Fritz B, Agten CA, Boldt FK, et al. Acetabular coverage differs between standing and supine positions: model-based assessment of low-dose biplanar radiographs and comparison with CT. Eur Radiol. 2019;29(10):5691-5699.
2. Hanson JA, Kapron AL, Swenson KM, et al. Discrepancies in measuring acetabular coverage: revisiting the anterior and lateral center edge angles. J Hip Preserv Surg. 2015;2(3):280-286.
Wiberg G. Studies on dysplastic acetabula and congenital subluxation of the hip joint with special reference to the complication of osteoarthritis. JAMA