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[Physio Explained] Hip dysplasia uncovered: from misdiagnosis to management with Alesha Coonan

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In this episode, we discuss everything about hip dysplasia. We explore: 

  • How hip dysplasia presents and common misdiagnosis
  • Key subjective questioning
  • Milestones in childhood and the relevance for hip dysplasia
  • Importance of education around the pathology

Want to learn more about Hip dysplasia? Alesha Coonan and Dr Michael O’Brien recently did a brilliant Masterclass with us called “The Clinician’s Guide to Hip Dysplasia: Assess, Treat, Manage” where they go into further depth on this topic. 

👉🏻 You can watch their class now with our 7-day free trial: https://physio.network/masterclass-coonan

Alesha is a titled Sports & Exercise Physiotherapist who works at Melbourne Orthopaedic Group (MOG) Sports Medicine in Melbourne, Australia, treating a wide variety of hip and groin conditions. In addition, she is a tutor with the Hip & Groin Clinic, who provide courses to experienced physiotherapists in the management of hip and groin pathologies. She is involved in clinical research looking into the management of adolescent and adult hip dysplasia and has recently completed a trial looking into the treatment of circus performers with hip pain. 

If you like the podcast, it would mean the world if you're happy to leave us a rating or a review. It really helps!

Our host is @Sarahyule from Physio Network

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SPEAKER_01:

So I suppose when you're looking at how do they present, they're probably that patient who've come to you after already seeing a number of different physios or myotherapists or PTs, and they're not quite getting on top of the symptoms. They just keep representing and they keep going two steps forward, one step back.

SPEAKER_02:

How does hip dysplasia present clinically? And what are the most common misdiagnoses? Today we dive into these questions and more with Alicia Coonan, a titled sports and exercise physiotherapist who works at Melbourne Orthopedic Group Sports Medicine in Melbourne, Australia, where she treats a variety of hip and groin conditions. Alicia is also a tutor with the hip and groin clinic, educating experienced physiotherapists in the management of hip and groin pathologies. She's actively involved in clinical research, looking into the management of adolescent and adult hip dysplasia, and recently completed a trial treating circus performance with hip pain. Her background in elite sport is extensive, having worked with the Australian women's soccer team, the Matildas, as well as Cricket Australia and Cricket Victoria. Alicia has done a masterclass with Physio Network on this topic, where you can explore hip dysplasia in even greater depths than we were able to today. Be sure to click the link in the show notes to access a seven-day free trial. You're going to love today's episode. I'm Sarah Yule, and this is Physio Explained. Well, welcome Alicia and thanks so much for joining us today. Thank you for having me. So I think we'll dive into the first question, which is how does hip dysplasure present? What's a great question?

SPEAKER_01:

I suppose in the vast majority will see the average individual presenting normally around their late teenage years and sometimes into their early 20s. It does depend on the severity of the dysplasure. So those that are quite severe will often present earlier in the teenage years. Those who are in the mild to moderate category are both often around that kind of early 20s. And then those who are in that more um mild category, probably normally more in their late 20s, if not early 30s. And they're classically the ones who come to you who have often had hip pain for an extended period of time. And it's often without a main mechanism of injury or a point in time where they're like, this is absolutely where I injured my hip. It's more the case of a gradual onset that's been kind of niggling in the background and then eventually just gets to that stage where it is building up, building up, building up to the point where that affecting either their day-to-day function or affecting their sports performance. So for a lot of our individuals in their teenage years, you'll find that they can be good for their first couple of years of doing, say, domestic and rep sport. And then as they get into that mid-teenage years, then they'll start to present with hip pain. And the the type of pain is kind of indicative of the type of hip dysplasia they might have. So an example for that might be that when we talk about hip dysplasia, we talk about different types. And more broadly, we can talk about a global type of hip dysplasia that I suppose everyone's quite familiar with, which is just the kind of undercoverage overall of the ball into the socket. And they're the ones who present with pain at the front, the back, or the side. There are those who will come to us with pain in the front of the hip. And that's often because they have the type of dysplasia called antiversion where they're basically undercovered at the front. And then you'll have another type called a retroverted hip or retroverted dysplasia. And they're the ones that are kind of overcovered at the front but exposed at the back. And they'll be the ones who present with kind of posterior hip pain or even a cramping sensation in their glutes. So again, they can present in many different ways, and it's why they often present after having multiple presentations of hip pain for some up to five years. They can have hip pain before they're actually diagnosed because they're often misdiagnosed based on where their pain is. So those that are those antiverted where they're getting pain at the front of the hip because they're exposed at the front, they're the ones that might come to you and they present with a pseudo hip flexor tendinopathy. And they'll often give you that anterior hip pain. So they'll be told that they've got a psoas tendinopathy or height hip flexors for a number of visits before someone realizes that that's not probably their natology. Those that get the lateral hip pain might be the ones that are presenting to you with a gluteal tendinopathy, which probably doesn't really fit the clinical picture when they're only in their early 20s and haven't drastically changed any load. And then there are the ones who get that posterior pain and are sometimes told they have like a piriforma syndrome. So they are classically the ones that are presented to multiple practitioners, on average, around three to five practitioners. And they can take anywhere, like I said, up to five years to diagnose. So I suppose when you're looking at how do they present, they're probably that patient who've come to you after already seeing a number of different physios or myotherapists or PTs, and they're not quite getting on top of the symptoms. And they just keep representing and they keep going two steps forward, one step back. So that's probably an overview of how they would present. There are upset classically the ones that we see as babies, obviously, and they're obvious. A lot of the time they'll be picked up by the obstetrician. And there are some in their kind of early infancy or those four, five, or six-year-olds we might see that have hip pain. But I think we're all pretty good at seeing kids and knowing that pain that is prolonged is not a good thing, and to often then send them off to um those above us, doctors or sports doctors.

SPEAKER_02:

It's a fantastic summary. So it's sounding like that sort of key subjective indicator of multiple therapists is obviously one question that we can ask. And then obviously asking about adolescence and childhood history of hip dysplasia. Are there any other key questions that we might be able to ask as clinicians that might help differentiate from those misdiagnoses that you've listed before?

SPEAKER_01:

Yeah, absolutely. I think any kind of presenting a physical complaint, we look for patterns and they can be in the form of aggravating factors and easing factors, obviously. But in dysplasure, it can be quite obvious, which is handy because it can kind of lead us down the path of what type of dysplasure we're looking for. So if we're talking about that, those different types of dysplasure again, the antiverted, the global dysplasure, and the retroverted, if they're someone who has an antiverted, so again, they're undercovered at the front and they're being given that misdigotus of hip flexor tendinopathy, they're the ones who are going to come into you telling you that they get pain with walking, particularly when that leg is the trail leg in extension. They'll be the ones who get pain after stretching, but they feel like they need to stretch every single night to release their hip flexor, but then it ironically makes them worse and they feel like they need to do it again the next day. They're also the ones that can get quite aggravated from yoga. And so they'll often get really sore, often later on, but they'll also be quite gifted in things like yoga. So they'll often have that extensive range and then try and push into it. So we broadly call that an extension pattern. When they're coming into you telling you they're getting pain with extension, there's that other group, that retroverted group I mentioned, who are the ones who are overcovered at the front and then exposed at the back. They're the ones who tell you that when they're doing ground balls in footy, they're getting glute pain or type of cramping. They're the gym goers who tell you they get kind of sitting a restriction at the front when they're doing deadlifts, but they get that same cramping sensation in their glutes when they're going into depth. The same with lunges or Bulgarians. And that's that kind of classic type of retroverted presentation. They can also get pain with sitting. The sitting is a really common symptom for hip dysplasia. It can be because of the pure impingement at the front for those who are overcovered at the front, but it can also be the undercovered ones at the front, the antiverted ones, because they sensitize those anterior structures like their hip flexors and their capsule and a couple of the bursa through their extension activities. When they do that opposite movement and then they sit down, they squash all those soft tissue structures up. So then that also what we'll often do is just kind of extrapolate where they're getting their symptoms and when and how they're getting them and what that sensation actually feels like as well. But they're kind of the big patterns or the aggravating factors we'd look for. There are that, obviously, those true mechanical sides and symptoms that we might be in a dysplastic hit. So the vast majority will click, but it won't necessarily be painful. A lot of them can have a sense of instability and they'll use their own words to describe that, whether it just doesn't feel right, doesn't feel like it's in the right place, feels like it's moving. A lot of them are very good at actually telling you exactly what it is and usually where that kind of instability is as well. So I think depending on the research you read, anywhere up to 80% will tell you that they have that sense of unease of the ball in the socket. And it's probably important to note that unfortunately the vast majority are female. So if you've got a female walking into your clinic with hip pain that is long-standing beyond the best part of four to six weeks, then for us it's hip dysplasia until clinically proven otherwise because of our hormones, because of our makeup, we are more predisposed to hip dysplasia and we certainly present more often. And interestingly, we present with symptoms of hip dysplasia compared to a male counterpart who may have exactly the same structural dysplasure and the same degrees, whether it's mild, butrical, or severe, but they will essentially not get symptoms from it. And the theory is that hormonally we are more lax, and so as a result, we do feel more instability from the dysplasure as a result.

SPEAKER_00:

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SPEAKER_02:

That's a great summary. I think there's a few excellent points from that. And it sounds to me like going back to that misdiagnosis commentary, there's some key subjective clues of how someone will describe instability that are quite different to a gluteal tendinopathy or a hip flexor pathology as well, which typically wouldn't describe their hip pain in that way.

SPEAKER_01:

Absolutely. I think as practitioners, we probably need to be better at listening to what the patients are actually telling us rather than obviously trying to guide them into answers that we want to hear, because a lot of them are very in tune with their body by that stage. And like I said, yeah, they can tell you the answer. There will be a couple of them who will also mention, and we'll often prompt this in our subjectives to what their childhood was like in terms of their uh milestones. So we know the obvious risk factors for hip dysplasia are female being breached and being firstborn, and that's largely just because we've got less room to move in the womb when we're firstborn. So we don't get to mould that born socket as well. We also obviously go through the birthing canal and it's tighter hit than most of it. So that does increase your risk of hip dysplasure as well as obviously being a twin or a triplet, if again, you squashed in with your brothers and sisters. But the other ones will often ask for milestones. So a lot of the dysplastic hips will talk about having extremes of milestones. So they might be really early to walk, so before a year, often around that nine-month part. And that group will often have missed crawling. Sometimes the patients can't always answer this, depending on um, yeah, their information from mum and dad. But a lot of them will be able to tell you that, oh yeah, no, they mentioned that I just, you know, I went straight to walking and I was really early and I was always on my feet, or I was a bum shuffler and I never crawled. And they're kind of slight indication that maybe they don't have that nice formation of the ball in the socket. And as a result, they don't want to crawl because they feel like they're impinged, so they just get straight up into standing where they're more in neutral or extension. And then conversely, you might have the ones who have a severe degree of global hip dysplasia, and they're the ones who are going to take longer to stand up because they just don't feel stable on their basically their socket. And so they'll be the ones who are a bit more wobbly, a little bit more clumsy, particularly in their early years, and they'll often be a result of having a globe dysplasia. Probably the other factor is the intowing and the outtowing, and I'm sure we've all had patients who present with their kids for the concerned. It can be a risk factor or it can be a sign of hip dysplasia, because we know that dysplasia is not just about the acetabule, it's also about the femur. So the femur can be too antiverted or retroverted, and that can dictate positioning. So we will always ask, did you intow or outtow as a child, or even toe walk for an extended period of time? And they can kind of be a little bit of warning signs that there might be some type of version in the femurs or something to do with the behema and the acetabulum.

SPEAKER_02:

On that, if you do have young patients that present with intowing or outtowing, at what age would you investigate further or or what sort of discussions do you have with parents and patients?

SPEAKER_01:

We're um fortunate enough to work within our multidisciplinary orthopedic surgery and sports medicine surgery. So we have access to surgeons who specialise in pediatrics, and we've obviously breached this with them a number of times, and they all agree that basically they wouldn't intervene at any stage unless there is pain or true lack of function. So that someone who is saying in towing and they run and it's so bad that they keep tripping over. We know that everyone is born with antiversion, and then as we get older, we turn out, and that turnout happens until the age of eight. So basically, under eight, you kind of just reassure the parents, you can do a little bit of training work to try and help to improve it. But outside of that, they don't need to be seeing the orthopedic version because I'll just say, keep doing what you're doing and see me once we've got past that eight or nine-year-old phase. And if they're still having dysfunction or pain from it, then they'll look to address it. But just purely aesthetically, it doesn't matter. What we've got to be careful with is that group beyond the age of nine or ten, where they're they've finished all of their growing and their rotation and they're still intowing. They're intowing normally because they are antiverted in that femur. So they intow to bring the femur back into the socket. And so you'll often find with that group, if you're trying to then tell them, no, no, no, you've got to stand neutral because mum and dad want you to stand that way to actually look straight, you're actually then going to undercover the femur or essentially overcover it, depending on the type of version, and that can create more hip pain. So we don't change gait in that sense, and we certainly don't do it into the teenage or adult population. We allow people to stand that they the way they want to after that age, because it's often protective. The body's actually trying to help uh keep that ball located into the socket a little bit more.

SPEAKER_02:

Which is probably fantastic advice for a parent as well. And I suppose, in terms of the education that we give our patients, linking pathology to why we're doing something as well. And just on that, you mentioned earlier with those patients that are antiverted, that love the stretching and feel like they need to release their hip flexors, but it's obviously making them worse. How do you go about educating them around why stretching isn't necessarily most the most helpful strategy for them? And do you link it to the pathology?

SPEAKER_01:

Great question. And absolutely, I think education is 90% of what we do now as physios and giving them a framework to then understand and have that control of their pathology so that they're understanding as to why they're getting pain and that the pain is not necessarily a really scary thing. It's just a protective mechanism. But from that example, I literally tell them that they've got a ball and socket and that they are what we call antiverted, so they're a little bit more exposed at the femur and they're overcovered at the back. I then show them a little funky diagram I have that shows them all of the hip flexors that come down through the front and the hip capsule. And I literally show them that if you're stretching and you're going into a hip flexor stretch, you are pushing that femur into all of those soft tissue structures. And you're basically bashing the strong word, but you're basically hitting up against those structures repetitively when you're going into hip flexor stretch. And I show them the hip flexor stretch and I'll show them a quad stretch. And so you're not actually stretching those muscles, you're just pushing a femur into them, basically, and that's going to make them red, raw, and sore. So if we keep stretching, that's all you're doing is you're moving that femoral head beyond where we want it to be, and you're probably stretching those soft tissue structures that are already vulnerable. So I explain that the poor hip flexor is actually trying to basically pull the ball back in the socket, and it's kind of a protective mechanism. It's deliberately tight because it's constantly being pushed. And that if we look at that more of that as the kind of victim in between, and that the kind of perpetrator is the ball in the socket, that we want to get more strength, stop the ball going forward in the socket and hitting the hip flexors and making them tight. And if we can control that ball a little bit more in the socket, they're not going to get that tightness and that need to stretch over and over again. And I think a lot of the time if you explain it in really simplistic terms, that they then understand that, okay, that oh, that's my pain, and that's why that doesn't work. And you can kind of see things like just clicking in their head going, well, that makes so much more sense. But these patients are often gifted in their range. They're ones who were dancers or gymnasts when they were growing up, or they're into phalisthenics or karate or those types of things that rewarded range of motion. And so they often still like to do yoga. So it's really about just explaining the pathology and the kind of giving them some parameters to work within and not putting a black line through everything.

SPEAKER_02:

Fantastic. Well, that was such a clear and practical discussion today, Alicia. So thank you. I think we've covered how disclosure presents, the common traps with misdiagnosis, and some really useful strategies for modifying uh activity. And I'd encourage those listeners that are wanting to hopefully go further. Alicia's created a fantastic masterclass with Physio Network where you can dive a whole lot deeper into this topic than we were able to today. So be sure to access it via the link in the show notes and explore it in even greater depth. Alicia, thank you so much for joining us and sharing all your wisdom. Thank you very much, Sarah, and thank you to our Physio Network.