Hip Dysplasia CaseFile

Keywords; hip dysplasia casefile, chiropractic help, hip, sacroiliac joint treatment.


A 59 year old man presented at our clinic with sharp stabs of pain in the right groin that began approximately six years previously. An ache radiated down the front of the thigh to just below the knee.

He remarked that he had regular chronic mild lower back pain, but only rarely did it really trouble him.

The pain in the groin began gradually; it was intermittent but in the last six months it became much worse. He had difficulty reaching his shoe, walking caused sharp discomfort, and even cycling was restricted. Climbing stairs was painful.

Remarkably, as most people have no idea how their mother's pregnancy went, he knew that he lay in the transverse position; she had told him.

Physiotherapy had brought a little temporary relief. Otherwise, nothing relieved the pain.

The ten questions in the questionaire at the bottom of this page will enable both you and your chiropractor to gauge just how badly your hip pain is affecting your general life style. He rated his condition as an eight.

In this hip dysplasia casefile the patient stood with a distinct lop sided posture. A short left leg tilted his pelvis giving him a mild C shaped scoliosis.

The ranges of motion of the lumbar spine were as follows. Flexion was mildly pain in the low back. Backward bending and sideways to the left produced right lower back pain.


Range of Motion of the right hip:

Flexion was severely limited to no more than 90* with a very hard "end-feel". That's typical of bone on bone. On flexing the hip to his chest, noteworthy was that he could only achieve it by simultaneously abducting the hip outwards. Likewise adduction, pulling it towards the opposite shoulder, was extremely restricted and caused sharp stabs of pain in the groin. Rotation, extension and abduction were relatively normal.

Motion palpation: The right sacroiliac joint was severely fixated (what I call a "feel of concrete" in the joint. It appeared "ankylosed".). Likewise there was a fixation of L5, the lowermost lumbar bone.

Orthopaedic testing:

Sacroiliac tests were negative. Yeoman's test produced mild L5 pain but nothing in the hip or SI joint. The Patrick Fabere test was normal surprisingly. Straight leg raise test of Lasegue only produced pain in the groin, ie. it was negative for a pinched sciatic nerve.


RADIOLOGICAL EXAMINATION

The radiologist's report reads as follows.

The right acetabulum lies more steeply inclined than the left hip. The cephalad portion of the hip joint is reduced in size, having worsened since the examination in 2005.

Bilaterally, there are degenerative changes occurring at the lateral margin of the roof of the socket. This has the appearance of a moderate Cox arthritis of the right hip associated with the mild case of dysplasia of the right acetabulum; normal sacroiliac joints.



Additional notes:

  • Note the typical features in the right hip of developmental hip dysplasia; that's your reading left. The inclined, sloping acetabulum compare with the slope in the left hip and the unroofed portion of the ball of the hip.
  • In the left hip there is concommitent femoro acetabular Impingement Syndrome Pincer.
  • The tilted pelvis due to a short left leg.
  • The mild curvature and degenerative changes of the lower lumbar spine.


DIAGNOSIS

Developmental Hip dysplasia casefile. DDH.


TREATMENT

Hip dysplasia casefile


CONSULT 1 : (17 June) HISTORY AND EXAMINATION

Subjective: Right groin pain.

Objective: Moderate to severe loss of flexion and adduction.

Assessemnt: Right hip dysplasia casefile.

Plan: Hip and pelvic exercises.


CONSULT 2 : (26 June)

S: R groin pain.

O: No change

A: DDH, X-rays have arrived.

P: Report of Findings.

  1. Briefly go through the history. All correct? Yes.
  2. Review findings of the examination.
  3. View the X-rays together. Note features of DDH.
  4. Explain something of the philosophy of chiropractic, particularly in this instance how fixated joints (his hip) has led to arthritis as the hyaline cartilage in the joint is starved of nutrients and oxygen, and waste products are not flushed away causing " immobilisation arthritis ". HYALINE CARTILAGE ...

    IMMOBILISATION ARTHRITIS ...

  5. What form the treatment will take, and the frequency. The importance of the three phases of treatment: 
  6. Treatment phase: 2/w x 3-5 weeks, depending on progress.
  7.  Rehab phase: Less treatment, more emphasis on exercises, and maintenance of the condition by the patient. 
  8. Maintenance phase: No one can cure the condition. Occasional (probably 6-8 weeks) treatment to sustain the expected improvement.
  9. Nutrition: to be discussed later.

First Chiropractic treatment of the sacroiliac joints, lumbar spine and hip joint.

CONSULT 3 : 1 July

S: Hip definitely feels looser. No "after pain" from the treatment.

O: No change in the objective findings of this hip dysplasia casefile.

A: Progress.

P: Add Mulligan belt mobilisation of the hip.



CONSULT 4 : 6 July

S: Increased pain in the low back.

O: Extension and increased flexion low back pain.

A: Low back in unstable phase after first few treatments: aggravations.

P: Change in treatment of L5. Right-side-down chiropractic adjustment of L5. Supine Thompson drop treatment of the right SIJ. Mulligan mobilisation of the right hip.

CONSULT 5 : 10 July

S: Much less back pain since last treatment. Groin pain still severe when walking. Range of motion of the hip increasing.

O: No lumbar flexion pain. Hip flexion still restricted to 90 degrees. Adduction improving.

A: First range of motion increases, then pain should decrease.

P: Nutrition. Discussed the need for nutritional support for the cartilage in the hip joint. Recommendations:

  1. Great increase in fatty fish in the diet to increase Omega 3 essential fatty acids, and vitamin D, vital in good calcium metabolism. MACKEREL RECIPES ... more about Omega 3.

    SMOKED SALMON DIP RECIPE ... more about vitamin D and why it's so essential.

  2. 1000 mg Cod liver oil per day.
  3. Chicken bones extract for a delicious soup is useful in the management of Hip dysplasia casefiles. CHICKEN BONES BOUILLON ...

  4. Freshly ground Flax seed with muesli every day. CHIROPRACTIC HELP Obesity in the Chiropractic Clinic and the virtues of Omega 3 in Flax seed.

One big plus: Mr F's weight is perfect.

CONSULT 6 : 13 July

S: Improving. Minimal back pain, Walking improving.

O: Pelvis still obviously low on the left.

A: Time for a heel lift. 5mm lift in the left shoe immediately reduces extension pain in the low back.

P: As before.

CONSULT 7 : 20 July HIP DYSPLASIA CaseFile

S: Magic. 80% less pain in the groin. Can now walk without pain, first time in six years.

O: Hip flexion still limited to 90*. "Concrete feel" in right sacroiliac joint is gone. Normal movment of SIJ on motion palpation.

A: Hard end-feel in the hip is much improved.

P: Mr F can flex his hip another 20* after the treatment. Must continue with the exercises to maintain the increased range of motion. Next consult two weeks. Begin rehab phase, and begin treatment on the left hip FAIS.

CONSULT 8 : August 8.

S: Mr F is a different man. Walking is almost normal, certainly painfree, though he does have a slight limp on careful scruteny.

O: For the first time hip flexion BEFORE the treatment now exceeds 90*. Adduction remains very limited. No abnormal sacroiliac findings.

A: He's doing better than expected. The interesting question is to what extent the Chiropractic adjustment of the sacro-iliac joint subluxation is what has restored his walking, and how much to do with the actual treatment of the hip itself.

P: Add further pelvic stabilisation exercises. Treatment as before. Next treatment in four weeks.

Note: I personally have gone into semi-retirement, and have left the care of Mr F to my colleague. No further updates to this casefile.

DISCUSSION of this Hip Dysplasia casefile

  • Mr F has a mild case of Developmental hip dysplasia. Mild enough to not have been picked up at birth by the paediatrician and mild enough not to be noticed until he was in his early fifties.
  • But bad enough to seriously change his lifestyle in his mid fifties, cause severe groin pain, and bad enough if left untreated to lead to a total hip replacement in his early sixties. Though the improvement in only four weeks is most heartening, he may still need major hip surgery.
  •  Inability to walk and cycle readily has meant Mr F has become mildly disabled, and without treatment would become seriously so within a short time.
  •  His doctor, in Mr F's forties, never examined his hip or, if he did, he never knew what Chiropractic could do for hip joints.
  • We give lip service to "a stitch in time..." and "prevention is better than a cure" but in practice Medicine seems to place very little emphasis on prevention in the management of joint conditions. Had this condition been detected 10-15 years ago, when the first signs were surely evident to the discerning doctor, it would have saved Mr F a lot of pain, and his medical insurance a total hip replacement.
  • In the USA a typical hip replacement in 2010 costs in the region of $40 000. Add to that the rehabilitation, several months out of work, the risks of embolism and the anaesthetic... it's high time primary care physicians were taught to examine the hip for early restrictions of motion, and to refer them appropriately. Any thing less comes close to negligence.
  • Health is additive. Mr F has two causitive factors: The well known increased incidence of hip dysplasia associated with transverse position in utero (and a breech birth). And he has a short leg. Leg length inequality research also conclusively indicates that the increase in the wear and tear on hips and knees associated with a short leg causes arthritis. A simple heel lift in his twenties... an equally simple set of exercises for his hip in his forties, and things would be very different today for Mr F.
  • LEG LENGTH INEQUALITY RESEARCH ... 


Hip pain questionaire

Pain is very subjective; this hip pain questionaire will help you gauge just how real your pain is.


USEFUL LINKS @ HIP DYSPLASIA CaseFile


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Interesting challenges of the day

1. Mrs D, a 78 year old woman has very severe sacroiliac joint pain, and even more severe cramps in her right leg. There are two problems; she is on two diuretics but no slow K. Taking her temporarily off one diuretic and adjusting the SIJ brought 50 percent relief within four days. 

2. Mr S, a 48 year old man, has right low back pain, groin pain and a numb feeling in his lower leg when he sports. For six months he's been off football. He too has two problems; a very treatable lumbar facet syndrome and a very serious blocked artery in the groin; it's called intermittent claudication. Smokers beware.  

3. Mr S looks like the leaning tower of Pisa; he has a slipped disc at L5 making him lean towards the opposite side. It's called the postero lateral disc hernia; we'll fix it, but he has to stop for a week or two. Antalgias are serious so take them seriously. 

4. Mrs V too has  two conditions; a chronic low grade sciatica giving her an ache in the right leg, and a threatening Morton's neuroma. She's glad I'm back in Holland; chiropractic fixed it before, and we'll fix it again. 

5. Mrs W is one of the lucky ones, says her doctor. I agree. He says only 40% of patients with lumbar stenosis have a successful operation. We fixed a nasty slipped disc three years ago, but it came back two years later; the surgeon did a fine job but she has a weak ankle now giving her subtalar joint pain; it's routine stuff. 

6. I myself had an acute exacerbation of a femoral nerve lesion last year. One immediate treatment of the new strain by my colleague has fixed the pain in the lower back, but there's some residual numbness in the lower leg; no soaring tomorrow alas.

7. This lady is a 86 year old woman with a 63 scoliosis. Chronic lower back has been her lot in life but she's well pleased with chiropractic and comes for chiropractic help once a month; some conditions you can never cure.

8. She is an 78 year old woman, is doing remarkably well with a bad sciatica. But over 200 pounds she is not losing weight; in fact, gaining despite my suggestions. She's high risk for a stroke. I have referred her to a dietician to crack the whip.

9. A 61 year old man with upper cervical pain yesterday; it's not severe but also not getting better of its own accord. He's afraid it may turn very acute as when I treated him three years ago. Since then it's been fine. 

10. A 64 year old woman has had scheuermanns disease; it's left her with a spinal kyphosis and chronic middorsal pain. She responds well to chiropractic treatment provides she come every six weeks or so for maintenance treatment.

11. Mrs C has been having severe headaches, and taking a lot of analgesics. It's a non complicated upper cervical facet syndrome, and she's doing well.

12. Mrs D, a middle aged woman with hip pain of one year duration, despite other treatment. Xrays reveal an impingement syndrome and early hip arthritis. There's much to be done.

13. Mrs B has had one of the nastiest of conditions; vertigo caused by a disturbance in the inner ear. Falling repeatedly and vomiting she consulted her doctor but medication didn't help. After two sessions of the Epley manoeuvres she was 50 percent better. After two weeks 75 percent improved. No longer vomiting all falling. She's not enjoying the Brandt Daroff home exercises.

And so the day goes; chiropractors shouldn't be treating the elderly most medical sites state but that's so much bunkum.



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