Private Eyes on the Hip—Sometimes a Culprit in Pelvic Pain and Pelvic Floor Disorders

sometimes a culprit in pelvic pain and pelvic floor disorders

STRUAN H. COLEMAN, MD, PHD

Editor’s Note: Dr. Byrd’s wonderful historical perspective in the previous chapter pointed out clearly at least 5 things:

The field of hip arthroscopy is still in its infancy. Therefore, the thinking within the field remains pretty basic. Current practice focuses on intrinsic activities within the ball and socket, and not on extra-articular contributing factors, such as femoral version, pelvic tilt, or lumbar curvature.
Right now, hip arthroscopists see different groups of people. At one extreme, people have lots of radiological imping ement but no symptoms. At the other extreme, people exhibit severe signs, symptoms, and progressive disease. What defines these differences? It is doubtful that the answer is solely athletics. It may be like a perfect storm, with multiple factors at play, such as pelvic orientation, muscle anatomy, the person’s specific movements. The best ultimate answers may come from the question: How do some people compensate so well life-long with such severe apparent misalignments?
It is unusual to observe symptomatic femoroacetabular impingement (FAI) in adolescents and young adults unless they are involved in athletic activities.
We are getting better at hip arthroscopy, but the answers are not all in. Hip arthroscopists are onto something good.
But our knowledge base is nowhere close to perfect. The correlation of the hip with core muscular anatomy is a prelude to future understanding.

The ensuing chapters go into various aspects of new clinical and anatomic understandings of the hip. In this chapter, Struan Coleman, head of hip arthroscopy at the Hospital for Special Surgery in New York City, describes the development of his special expertise in hip arthroscopy for women or men with pelvic floor pain. He has become the best-known surgeon in this expanding clientele of patients. Also a gifted sports orthopedic surgeon and team physician for the New York Mets, Struan has dramatically good results with this complicated group of patients. In the chapter, Struan becomes Sherlock Holmes. He regards the patients with severe, chronic pelvic pain sitting (or, more accurately, standing because it is too painful to sit!) in uro-gynecologic offices as great mysteries. He writes the chapter like Sir Arthur Conan Doyle. His gynecology colleagues play the role of Watson.

NOT JUST ANOTHER DAY AT THE BEACH (FIGURE 23-1)

Figure 23-1.

By way of introduction, I am a sports medicine orthopedic surgeon working in New York City. I have a particular interest in disorders of the hip in young people. In 2008, Sarah, a 26-year-old athletic woman, came into my office complaining of groin pain for more than 2 years. Sarah described a dull ache in the groin with occasional “catching, locking, and popping.” Sarah experienced this groin pain with sitting, getting in and out of a car, and with all activities involving rotation of the hip joint. Sarah had completed multiple rounds of physical therapy and activity modifications without relief. Sarah’s pain was getting worse and was now interfering with most of her daily activities. I asked Sarah about some of those activities. I was to learn that I did not ask about the important ones.

After examining Sarah, I concluded that Sarah was suffering from a hip disorder. I sent Sarah for a number of imaging studies: X-rays of her hip and pelvis, an MRI, and a 3-dimensional CAT scan of the hip. At her second visit, I explained to Sarah that she had a condition called femoroacetabular impingement, or FAI, in which excessive bone next to the ball of the hip joint was rubbing on the rim of the socket. Moreover, the impingement had torn her labrum, an “O-ring” that runs around the rim of the bony socket and creates a seal with the ball. I recommended a surgical procedure using an arthroscope (a tiny camera introduced into the joint) to repair the torn labrum and remove the excess bone at the top of the femur. After discussing potential risks and benefits of the procedure, Sarah set a date for the surgery and left my office. Two months later, Sarah underwent the surgical procedure. At the time of the surgery, it was noted that her psoas tendon was red and excessively tight and so we performed a psoas lengthening in addition to the other procedures.

Three months after the surgery, during her second postoperative office visit, Sarah reported that her hip symptoms had completely resolved and that she had returned to her daily activities without pain. Later that day, I received a call from Sarah’s gynecologist, Dr. Deborah Coady, who had surprising news. In addition to her hip pain, Sarah had been suffering for more than 4 years with another type of pelvic pain, a condition called vulvodynia. Vulvodynia is characterized by continuous burning pain of the external genitalia, and often associated with spasms of the pelvic floor muscle, painful intercourse, and bowel and bladder dysfunction. Dr. Coady was amazed. All of those symptoms had resolved as well following her hip arthroscopy. What had I done during the hip procedure that could possibly have affected Sarah’s vulvodynia? The truth was: I had no idea.

THE QUEST

This phone call with Dr. Coady sparked the start of a fascinating journey, namely, a quest to understand the association between impingement of the hip and pelvic pain.

I spent the next few months reading about pelvic floor pain and discussing these issues with Dr. Coady; her partner, Dr. Deena Harris; and Stacy Futterman, an extraordinary “internal” physical therapist, who had been treating patients with pelvic pain for many years. Over those few weeks, I learned about the extraordinary prevalence of vulvodynia in the United States; it affects 8% to 16% of women within their lifetimes. The problem leads to diminished physical, sexual, and emotional function in millions of women.^1–4 Vulvodynia is difficult to cure due to both insufficient understanding of the causes of pelvic floor dysfunction and the presence of co-morbidities.⁵ Treatment options for vulvodynia include specialized internal massage, intravaginal injections, topical medications, and, as a last resort, surgical procedures such as vestibulectomy (ie, removing parts of the external genitalia).

My treatment of Sarah swiftly generated optimism for Dr. Coady and her colleagues. For some of their patients with vulvodynia, there was hope. A relationship between the hip and “their” pelvic floor dysfunction would mean that treating the hip problem might resolve the pelvic pain. At the time, this seemed like a Eureka moment. But…there was more work to be done. The key was to understand the association between the hip and the pelvic floor.

We know that there is a close anatomical relationship among the hip joint, the pelvic floor, and the pelvic girdle. So, it was not too surprising that chronic inflammation inside the hip joint and surrounding structures might produce a variety of signs and symptoms within other areas of the pelvis.^6,7 We surmised that branches of the pudendal nerve may become irritated by an inflamed hip and/or iliopsoas tendon. Of course, we did not have all the answers, but advances in imaging, particularly MRI, together with the newer arthroscopic techniques, seemed likely to reveal some answers. Since 22% to 55% of all women have some sort of unexplained, chronic pelvic pain,8 certainly the hip might have something to do with the pain of at least some of these people.

Read just about any chapter of this book, and you know that hip impingement can refer pain into the groin as well as a variety of other regions around the hip. “Shared” muscles, such as the iliopsoas, obturator internus, and other pelvic floor musculature, plus the interweaving, regional connective tissue, make it obvious that all these musculoskeletal structures are connected. If you remain unconvinced of the Machiavellian nature of this region, go back and reread Dr. Aradillas’s chapter on the nerves of the pelvis. The bottom line: There are numerous anatomic pathways by which the hip can potentially interact with the pelvic floor.

Moreover, we knew that hip impingement leads to nonoptimal movement patterns or, more specifically, a change in the body’s normal kinetic chain.⁹ We considered this change in the movement of the pelvis in the setting of hip pathology. Certainly, it could result in spasm and dysfunction of pelvic floor musculature and eventually myofascial and/or neural (pudendal) vulvodynia. Read about the “generalized vulvodynia subtype.”¹⁰ This form of vulvodynia fit directly into our hypothesis.

Initial successes with Sarah, plus a second very similar patient a few months later, led us to construct an algorithm for the diagnosis and management of the “combined problem”—vulvodynia and hip impingement. We first identified suspected “combo patients” and screened them for hip pain, vulvodynia, and pelvic floor dysfunction. We obtained both a detailed gynecological history and physical exam and then a detailed musculoskeletal core history and physical examination. Specifically, we asked about both pelvic or groin pains or other symptoms associated with hip impingement: locking, catching, sitting, and getting in and out of a car. The most impressively overlapping symptoms were painful sex (dyspareunia) and painful sitting. The ones designated as combo patients then went for X-rays and MRIs of the hip and pelvis. When the history, physical exam, and radiographic findings all intertwined and pointed to pelvic floor dysfunction and hip impingement, we got ready to do more tests or treat them.

Let’s take a step back and go more clearly through our thinking. One of our hypotheses was that iliopsoas muscle irritation, secondary to the underlying hip impingement, caused the spasms and generalized pelvic floor dysfunction. Over time, irritation of the pudendal and other nerve branches then triggered the vulvodynia, bladder and rectal pain, and dysfunctions. We stopped at different points in the testing and performed selective injections.

Selective injections of local anesthetic and cortisone are used commonly in orthopedics and other medical specialties to determine which precise anatomical site(s), joints, or areas around joints might be causing pain. Sometimes we even use these sorts of techniques as definitive treatments for the pains. For these patients, we used the differential injections technique quite liberally. We felt this critical for the evaluation, plus to confirm (or not) involvement of the hip joint. After we injected the hip joints, we then waited designated time intervals in order to assess the results. (See Figure 23-2.)

Three main possibilities emerged in terms of results:

No apparent effect; therefore, it seemed the hip was not involved
Partial or complete resolution of most of the hip pain but no effect on the vulvodynia
Relief of both the presumptive “hip” pain and the vulvodynia

Result 3 was obviously the strongest indicator to proceed with hip arthroscopy. Result 2 usually generated another injection, this time in the region of the iliopsoas tendon. This additional injection might either diminish or flare up the pelvic pain. In either event, we would presume the iliopsoas to be involved, and this, too, would become an indication for hip arthroscopy, with the additional procedure during surgery of lengthening the iliopsoas tendon. If we could not demonstrate any sort of relief (or aggravation) of the pain by the injections, we would not operate, unless the patient had reasons other than vulvodynia to do so.