DYSPLASIA OF THE HIP
Developmental Dysplasia of the hip (DDH) is an umbrella term used to describe various bony abnormalities which result in poor containment of the ball of the hip (femoral head) within the hip socket (acetabulum). It is a condition where the hip joint has not developed properly and this can affect; the shape of the bones, the orientation of the ball or socket, or all the above. Ultimately there is a mismatch in the fit of the ball into the hip socket, meaning that the femoral head is not held tightly in place and therefore increased movement (shearing) occurs.
The labrum is a horse-shoe shaped ring of cartilage which sits around the rim of the hip socket. It helps provide further stability and a suction seal. In a hip with dysplasia, there is increased movement of the ball in the socket due to lack of bone support, the labrum becomes thickened and inflamed to try and support the femoral head better. Eventually, it can become torn from taking the extra load. This is called a labral tear. The labrum has many nerve endings within it which can contribute to increased pain when it initially tears. However studies show that up to 50% of people can have labral tears without any symptoms.
Up to 50% of people with hip dysplasia can also have joint hypermobility. This means that joints have a greater range of movement than normal because the ligaments and joint capsule are lax (loose). This laxity means that the femoral head moves more within the socket and can also contribute to the uneven stress on the hip joint.
With hip dysplasia the hip joint is less stable because of the mis-shaped bones and also because often the ligaments and capsule around the joint can be lax (loose). This lack of bony or ligamentous stability results in increased stress on the structures of the hip joint to try and contain the ball within the socket. There is increased shearing in the joint (there is a slightly greater amount of movement of the ball in the socket than in a normal hip joint). If hip dysplasia is undiagnosed or untreated, the natural progression includes development of pain, functional limitations and then eventually degeneration of the joint, also known as Osteoarthritis (OA).
People with hip dysplasia can start to develop OA in their hip joint earlier than others because of the uneven wear to the joint. Think of a car tyre. If it is not aligned properly the tyre will wear down unevenly. The greater the degree of dysplasia and the prescence of subluxation the higher the risk of development of OA. Symptoms Those with Hip Dysplasia can experience a wide range of symptoms starting at any age. Normally patients present with pain after prolonged activity, and it is eased with rest. Most people experience pain in or around the hip or groin, but some report knee or back pain. Pain may be intermittent or more constant, it can come & go from day to day, or only occur with certain activities. Some symptoms you may experience include:
Groin pain
Pain deep inside the joint
Pain at the front or side of your hip
Pain when your hip is flexed to 90 degrees & turned inwards
A limp or ‘waddling’ gait
Clicking, catching or locking in the hip joint
Feeling as if your hip will ‘give way’
Pain that is made worse by activity & relieved with rest
Some people experience knee pain, back pain or pelvic pain as well
Not everyone experiences all these symptoms, and you might experience different symptoms at different times.
If you find yourself with hip dysplasia as a young person or adult you may have had a previous diagnosis as a baby. This is called Developmental Dysplasia of the Hip (DDH). It is sometimes known as ‘clicky-hips’ or ‘loose hips.’ You may have had treatment such as a pavlik harness or plaster cast or surgeries as an infant or child and have residual hip dysplasia now. However, you may not have had an infant diagnosis. Your symptoms might have started developing as a teenager or young adult after exercise or prolonged standing.
The reasons why some cases of Hip Dysplasia are not picked up until later on young adult life are not fully known. One reason could be due to the fact that our current screening methods for Hip Dysplasia in infants don’t pick up every case. Another theory is that some forms of hip dysplasia develop during a growth spurt in adolescence and are linked to ligament laxity (hypermobility syndromes).
The causes of hip dysplasia still remain much debated and further research is required. However, there are some known risk factors that may play a part:
First born
Female gender
Breech presentation
Swaddling as a baby
The heritable component of DDH due to common genetic links is approximately 55%. (links with GDF5 gene)
Ligament laxity or hypermobility syndromes, or a family history of this - 47% more prevalent in DDH
It is not uncommon for people to find it takes a long time to find a clear diagnosis of hip dysplasia, the average time to diagnosis is 5 years. Dysplasia often masquerades as other issues such as tight muscles and there are no specific clinical tests that diagnose dysplasia. You may have found you have seen a medical professional or Physiotherapist who has treated these other issues initially but that it has not helped your symptoms. It is important that you see a Physiotherapist and Consultant who specialises in dysplasia.
Plain X-ray is the primary imaging technique used for diagnosis of hip dysplasia. An X-ray shows the bony anatomy, it does not look at soft tissue issues. Important x-ray measurements include the lateral centre-edge (LCE) - LCE angle is the most important angle to measure the lateral coverage of the socket over the femoral head. An LCE of 18-25 is defined as mild or borderling dysplasia. An LCE of less than 18 degrees is defined as significant dysplasia.
Other imaging investigations include Magentic Resonance (MR) scans. A scan that takes pictures of your pelvis, to show the bone, cartilage, ligament, tendon and labrum in more detail. MR scans are often used to assess the condition of the joint and to help decide on treatment options. CT Scans Provides a 3D image reconstruction of the bone anatomy which will help diagnose complex multidirectional deformity and aid with surgical planning.
Arthroscopy also called ‘Keyhole surgery’ can allow a surgeon to look inside the joint to help diagnose your hip problem. In some cases it can be used to treat certain hip problems too.
Treatment options
You will generally have 2 main options for treating hip dysplasia:
nonsurgical (known as “conservative” treatment) such as physiotherapy, modifying your lifestyle and pain management
surgical treatment to correct the shape of the hip socket itself. Surgical treatment to prevent OA developing in the hip joint is known as ‘Hip Preservation Surgery’.
Physiotherapy is a key conservative measure which can help improve your symptoms. Patients often present with poor posture, muscle weakness,poor joint position sense, and associated secondary issues such as gluteal or
psoas tendinopathy.
Physiotherapy should focus on:
Improving posture, core strength and pelvic position awareness.
Gait re-education - reducing stride length and preventing over extension of the hip.
Optimizing lower limb muscle strength, especially hip extensors and hip rotators.
Joint and body awareness exercises (proprioceptive training).
Education on nutrition, physical activity and self-management advice.
Pain-management techniques -understanding how pain works and how to manage it with pacing and relaxation.
Whether you decide to have surgery or not, physiotherapy will play a significant part of helping with your hip problems. Physios are specialist at diagnosing and treating joint & muscle problems to reduce pain. You will benefit from finding a physiotherapist
experienced in treating young adult hip issues and hip dysplasia patients.
You may find that modifying your lifestyle helps you manage your hips on a day to day basis, in the following ways:
Maintaining a healthy weight
Nutrition/dietician input
Stopping smoking - Smoking significantly affects bone healing if you are considering surgery- this is vital
Staying active with low-impact exercise such as swimming (frontcrawl) or cycling. Breastroke can sometime irritate pain but everyone is different
Making adjustments at work
Hip injections into the joint using local
anaesthetic and Corticosteroid (high dose anti-inflammatory) are often used as both a diagnostic tool and a pain relieving method. If the injection into the joint helps, this is a reliable indicator that the pain is coming from within the joint itself. Injections also help to break the pain cycle so physiotherapy can commence.
Sometimes watching and waiting and optimizing your conservative management strategy can allow information about your diagnosis to sink in and give you time to work out how best to manage your hip pain. Undergoing surgery is a big decision & it will be important for you to discuss with friends & family how employment, childcare & other arrangements would work if you do decide to go ahead with it.
The focus of Surgical treatment is to restore stability of the hip joint by correcting the structural deformity either on the femoral or acetabular side. Rarely in mild dysplasia an arthroscopy as an interim procedure may help relieve symptoms but will not address the underlying structural abnormality. The aim of surgery is to provide more optimal coverage of the femoral head, this therefore reduces the shearing forces acting on the joint reducing pain and delaying the progression to osteoarthritis (OA). The gold standard hip preserving procedure for the treatment of hip dysplasia before the onset of osteoarthritis is a Pelvic osteotomy or PeriAcetabular Osteotomy (PAO). Good surgical outcomes depend upon the right patients being operated on in a timely manner. Factors that have been highlighted to significantly increase risk in poor surgical outcomes include: High BMI, Aged >40, Evidence of osteoarthritic changes of the joint (once the joint has started to fail the benefits of a PAO are limited).
Pregnancy, relationships & family life
It is fine to get pregnant if you have hip dysplasia. Extra weight carried through pregnancy will increase the load going through the hip joints, which may increase your pain. If you have hypermobility, your hip pain can increase during pregnancy as the hormone relaxin increases ligament laxity in preparation for the birth- this results in less stability from the ligaments around the hip joints and can cause increase shearing and therefore pain. Physiotherapy, maintaining strong muscles and pelvic corsets can help with this. If you have had a pelvic osteotomy, this surgery does not encroach the birth canal and therefore you can deliver normally if you wish. Can I pass this onto my children? Hip dysplasia is approximately 12 x more likely when there is family history. If you have a diagnosis of hip dysplasia it is important that your newborn child has an ultrasound screening. (International Hip Dysplasia Institute). Can I still be intimate with my partner? Being intimate with your partner is a key part of your relationship but your hip pain may make you worried or anxious about this. The most important thing is to be honest with your partner about what is painful and uncomfortable. Positions that force the hips into extreme movement and full flexion may be more painful.Keeping your core stable, with your feet on something will provide improved joint position sense and reduce unstable feelings. Seeking support Receiving a diagnosis of hip dysplasia can be overwhelming. You might feel sad, angry, uncertain of the future or even relieved to find out what is wrong. All these feelings are normal. It’s important to know that you are not alone, there are many others with this condition, and seeking support (see final page for support groups), coping strategies & practical tips from others can be really beneficial, whatever treatment you decide on. It can also take a while for information about your condition to sink in.You may want to keep this leaflet to refer back to. You can find details of online support networks & further resources on the back page. If you have chosen to undergo surgery then talking to others with hip dysplasia can help you feel prepared for what to expect and what recovery will be like. One of the most important things in the journey of hip dysplasia diagnosis is acceptance of the diagnosis and then moving forwards. Believe in what you can achieve, not in what you cannot do. Optimism is the faith that leads to achievement. Nothing can be done without hope and confidence.
What does the future look like?
You may have decided what treatment you are having, or you may be unsure or still considering your options. Talk to your doctor, surgeon or healthcare practitioner about what is best for you. Don’t be afraid to ask questions about your future with Hip Dysplasia. Some people find that after surgery they are still prone to fatiguing with physical activity, and have to make work adjustments in the long run, especially with more physical job roles. Some find that they can return to impact sports, others find non-impact sports suit them better. Everyone is different and there are many factors which have an influence on people’s lives with Hip Dysplasia. There is a small but growing research base into Hip Dysplasia and our understanding of the condition is growing all the time. It’s important to remember that treatment options for hip dysplasia are aimed at reducing pain and delaying the development of OA in the joint. Therefore if you choose to undergo hip preservation surgery, you may still need to undergo total hip replacement at a much later time in your life. However, there is still a good possibility of going on to live a functional, pain-free life, and delaying a total hip replacement for many years.
For more information
International Hip Dysplasia Institute An international charity committed to researching & raising awareness of hip dysplasia www.hipdysplasia.org
I’m A Hippy An international website/charity/patient and professional network regarding hip dysplasia. www.imahippy.org
Steps Charity UK A charity supporting children & adults affected by paediatric lower limb conditions www.steps-charity.org.uk
DDH UK A charity providing information & support for those affected by Hip Dysplasia www.ddh-uk.org
‘Hip Dysplasia Physio- Information and support regarding Physiotherapy for Hip Dysplasia’ www.hipdysplasiaphysio.com
Hip Pain Help www.hippainhelp.com/acetabular-dysplasia/