Top tips for shallow hips (Part 3 - Dysplasia) - Management!

Let’s tally up what information we have so far.

Caucasian female with a 5 year history of buttock, groin and anterior thigh pain. Reports being hypermobile. Unable to recall if breech birth or clicky hips, no matter. Not currently sporty or loading enough to be susceptible to a reactive tendinopathy and unlikely to have persistent tendinopathy given her history. No inflammatory sounding night pain, early morning stiffness or personal/first degree family history of inflammatory conditions.

Not responded to any rehabilitation efforts or medications so far. Frustrated. Questioning if things will ever change. Is it all in her head if the X-Ray says there is nothing wrong?

Clinically appears hypermobile on Beightons score, we know that has positive associations with DDH. Excessive rotation profile at the hip. Symptoms are reproduced on hip joint testing.

At this point I would be thinking there is enough evidence to suspect DDH. If we hadn’t of had an X-Ray then maybe the best thing for Jade is to go and get one +/- an orthopaedic hip opinion. It’s not that she can’t still try rehabilitation to help, we can delve into what it is exactly that she has tried and experiment with other things whilst she is on this orthopaedic journey alongside.

As luck would have it she did have one and there is certainly enough suspicion to provisionally diagnose DDH. The next conversation… what are Jade’s concerns and expectations? Given her lack of progress to date and impact on her life, is a surgical opinion something she would like to seek? It is always going to be an option and the prospect of surgery is a scary thing. It might involve a pelvic osteotomy rather than keyhole surgery alone which is no small feat and Jade may or may not have strong thoughts about going down this route. If she is open to it and feels it might be necessary, then further discussions with a surgeon alongside some 3D imaging (CT scan) is probably going to be helpful.

If you aren’t comfortable discussing these topics then it’s best just to refer anyway. A surgeon will never be unhappy to see someone who they may provide significant benefit to by contributing to ‘saving’ the native hip and they can counsel on the pros/cons of any surgery.

This is now coming onto WHY it is so important we pick up on these patients. From a surgical standpoint, one of the key indicators for a hip preservation surgery is the absence of significant osteoarthritic changes on imaging. There is probably no great benefit to undertaking a big hip preservation surgery such as a peri-acetabular osteotomy if there isn’t much hip to preserve (REF). Unfortunately, if the boat is missed with a PAO the only viable surgical option in most cases is a total hip arthroplasty once the joint is arthritic enough to benefit. In patients with DDH, the labrum plays such a huge role compared to ‘normal’ hips (REF) so undergoing debridement isn’t desirable and repairs are likely to fail given the reason a tear might be there is the underlying hip morphology anyway. Cartilage procedures such as OATS or ACI won’t be considered as the joint itself is a ‘hostile environment’ for any osteochondral plug or implanted chondrocytes.

Frustration and anger is not uncommon for people who get diagnosed past the point of being viable for hip preservation procedures as demonstrated HERE, especially if symptoms have been going on for a long time.

We can make a big difference simply by picking up these patients earlier. They are a cohort that surgery could potentially be very beneficial for by changing the shape of the hip to spread mechanical stress out more evenly and reduce the rate of degeneration of the articular cartilage.

If someone doesn’t want to go down that road then that is absolutely fine too. But having a diagnostic label when there is such a clear one available for a lot of people will help them manage it better when their unexplained symptoms have been dragging on for years. And if they are counselled on DDH, the options and pros / cons of the options and they decide not to go down the route of operative management, it helps if we have an understanding of what might be going on with the hip on a tissue level (remembering the bio part of the biopsychosocial approach).

When it comes to physiotherapy management, we truly are in the infancy stages when it comes to the research. But our fundamentals of practice don’t change – assess the person as a whole, if you can address concerns that are really playing on the persons mind as this is low hanging fruit and actually just encouraging the person to be active / eat well / stop smoking (if relevant) is going to be the mainstay of treatment. Osteoarthritis is ultimately the enemy long term and that is multi-factorial. Yes DDH is a risk factor for OA (REF), but there is more to it than just hip shape and that is important to remember. If we can stave of systemic chronic inflammation and/or metabolic syndromes then this is going to help!

And given that the explanation for pain has been so mechanical so far, the patient isn’t to know that they should continue being active even if they have opted not to undergo surgery. They might not get this from a surgeon so it’s probably one of the most valuable things we can offer. People can still get good symptomatic improvement on a non-operative pathway.

Becoming more granular / zoomed in on what to do from a exercise prescription perspective, it’s unclear. A lot of people will talk about hip stability exercises; this is fine and probably a good starting point as they are low load exercises in likely irritable patients. Deep hip ‘stabilisers’ probably can’t do as much as you would think the stabilise the joint as they have small moment arms and the cross sectional area of gluteus medius alone. Additionally, in DDH the joint centre of rotation is more lateral which mechanically disadvantages our hip musculature even further (REF) If we are focusing on hip stability / joint stiffness then maybe it’s best to focus on the peak force of the larger muscles which stabilise the hip. Maybe deep hip stabilisers have more of a role in proprioception or re-directing the resultant joint reaction force in the joint (I’ve already massively gone over the word count for this blog so unfortunately I can’t dive into this further but I have some posts on my page exploring this a bit more).

‘More research is needed’… everyone’s favourite line!

So, there we have it. We have thoroughly assessed and reasoned Jade’s presentation, and presented her with the options moving forwards. What route she wants to go down is up to her but we have done our job of flagging this up as an issue. For the first time, there is some clarity and an actual viable path to improve things moving forwards both in terms of symptoms and coping, and the impact this could have on her psychological and social wellbeing.

Thanks to the team at the BCP for inviting me to write this blog, I hope you found it helpful. It won’t be long until the next ‘Jade’ walks through your doors.

 Cheers,

 Jeff

@jmortonphysio

 P.S. please also consider following @hipdysplasiaphysio who is a hip specialist physiotherapist with lived experience of DDH including surgical management!