Top tips to not miss shallow hips (HIP DYSPLASIA) Part 1

“I am 39 now in constant pain... my hip often gives way without warning.... I feel like an old lady... What does the future now hold for me?”

 The above is a quote taken directly from a paper that interviewed people living with Developmental Dysplasia of the Hip (DDH) and I think is a great way to start this blog as it illustrates the impact this condition has on the individuals living with it and is a reminder that we should be able to make positive impacts. From the off, I would really recommend reading THIS paper which provides an insight into just how much symptoms related to DDH can affect the social aspect of life from pre-post op. The guys at the BCP have correctly given me a word count for this blog as I can go on a bit, so I won’t go too much further into the lived experience side of things, but as I said… READ THESE PAPERS! (Edit: )

 I would argue that as physiotherapists, patients with DDH are coming through our doors frequently, but that the proportion with an actual diagnosis is quite low. If you search around on social media and in the research then the condition of ‘acetabular dysplasia’ isn’t hard to find information on… so why do people wait so long for a diagnosis? (Nunley et al reported a mean of 61.5 months for their cohort [Range 5 months to 29 years!])

 I don’t have the answer to that. I can take some guesses that include historical sexism in both research and clinical practice (as we will come on to see, DDH affect females disproportionately), plain ignorance of this as a diagnosis or maybe the relatively recent introduction of pelvic osteotomies as a treatment approach which may have delayed the interest in this as a topic. One thing we do have some data on is that DDH is very much undercalled on radiology reports (REF, REF), which could be a piece of the puzzle! Whatever the reasons – hopefully we can all do a little better as time progresses and if you are uncertain of where to even start, I have some good news for you… it’s not an incredibly hard diagnosis, it is more the awareness of this that is important!

 A woman in her mid 20’s, let’s call her Jade, walks into our clinic with a 6 year history of right hip pain. She has been seen by a few people in the past including a couple of GP’s and a couple of physiotherapists. Despite everyone’s best intentions and efforts, the hip pain that Jade suffers with has been gradually worsening. She has had an X-Ray ordered by her GP which has been reported on as normal. We ask Jade what she has been told is the issue previously to which you are met with a whole host of diagnoses ranging from gluteal tendinopathy to hip flexor tendinopathy and SIJ ‘dysfunction’. We collectively sigh. There hasn’t been an agreement between the previous healthcare professionals and this in itself is causing a lot of frustration for Jade. Surely there is an answer?

 As we are engaging with the BCP’s content and are a clued in, top shelf physios, we start to smell a rat. Tendinopathies of the hip are common in people who are quite active in running / sports e.t.c., but Jade can’t even think of doing that at the moment as it would massively kick off her pain. Our index of suspicion for a primary tendinopathy drops a bit.

 GTPS? Jade is only 25, she would be a massive statistical outlier for this condition. It’s probably more likely there is something else going on.

 SIJ dysfunction? Well, that’s just plain bullshit (although without more information we haven’t completely ruled out an inflammatory sacroiliitis yet – Axial Spondyloarthropathy patients also wait too long to be diagnosed!).

 The thought processes above are the first crucial steps in assisting with a diagnosis of DDH. People with symptomatic DDH often don’t present in a uniform way. It is common for people to experience a combination, or even just one of the following pain locations; groin, lateral hip, anterolateral thigh, buttock (REF, REF, REF). For Jade, she is experiencing buttock and groin pain into her thigh.

 If you aren’t aware of this, or aren’t considering DDH in your differential then it is natural to squeeze these symptoms into any number of other diagnostic labels just to try and make it ‘fit’. This is a trap I have fallen into many times in the past and is just human nature – uncertainty doesn’t sit well with us. The alternative is too much ‘type 2’ thinking where we have probably made our diagnosis and treatment plan before the patient has even finished their first sentence (I have embarrassing stories myself about this that I might write up one day to make everyone feel a bit better about themselves!).

 But thankfully, you are keeping DDH at the forefront of your differential diagnosis, because this story doesn’t fit. So, what questions do we need to ask the patient that will either raise or lower our index of suspicion for underlying DDH? To save on word count here I am just going to list them below and you can read more about them in the links provided throughout the blog.

• Are they hypermobile? (To be followed up with a quick Beighton’s score during clinical exam)
• Do they have a family history of hip dysplasia? (I also ask about family Hx of hip OA as historically DDH may not have been picked up in the family)
• Were they born in breach position?
• Have they experienced, or been told, that they had ‘clicky hips’ as a child?

 A couple of other questions we have to ask ourselves:

• Is the patient Caucasian?
• Is the patient female or assigned female gender at birth?

If we are getting multiple yes’ to the above questions then our index of suspiscion probably starts to increase in having DDH as a diagnosis.

(SIDENOTE: Ben often talks of ‘granularity’ of diagnosis and how specific do we really need to be; I love this approach and agree wholeheartedly. There are a couple of things that stand out to me for Jade that makes me think we need to be a little more granular in this situation. Hip pain for 5 years in a 25 year old is unlikely to be primarily soft tissue without the social history that goes alongside it, it hasn’t responded to rehabilitation (yes the diagnoses may not have been correct but would the rehab have looked drastically different? Something we would need to delve further into) and the main reason is that Jade has never had a satisfying diagnosis which can cause a lot of psychological distress. Sometimes just an answer can pave the way to coping strategies)

There we have the first steps in being able to pick up hip dysplasia as a diagnosis; be aware of it and question things that don’t fit. Then screen for factors that raise or lower your suspicion of DDH

Join me next time for what to be on the look out for from a clinical exam and basic X-Ray features!