Avascular Necrosis of the Femoral Head

Avascular Necrosis of the Femoral Head

Article by John Miller

Avascular Necrosis of the Femoral Head

What is Avascular Necrosis of the Femoral Head?

Avascular Necrosis (or Osteonecrosis) is a condition affecting the upper part of the leg – specifically the femoral head. Mainly, the femoral head or ball of your hip joint receives less and less blood supply.  Since bone is living tissue when this blood supply reduces enough, the bone dies. Once the bone dies, the femoral head collapses, and if severe enough, the hip joint itself collapses.

avascular necrosis of the femoral head

Avascular Necrosis mainly affects those aged between 20-50 years old. In general, the healthier you are, the less risk you have of developing avascular necrosis. It usually comes about secondary to an underlying health issue or previous injury.

What Causes Avascular Necrosis of the Femoral Head?

Avascular necrosis arises either as a result of traumatic or nontraumatic means. Sustaining a dislocated hip – where your femoral head becomes dislodged from its joint, can result in a traumatic onset of avascular necrosis. Up to 20% of people who dislocate their hip, develop avascular necrosis of the femoral head.

Nontraumatic avascular necrosis can arise from an array of issues, most notably excessive alcohol use, chronic corticosteroid use and blood clots/any damage to the arteries supplying the femur.

The pathophysiology behind the association of chronic corticosteroid and alcohol use with avascular necrosis remains clouded. The overuse of the substances as mentioned above interferes with the breakdown of fatty substances. Consequently, the fatty substances build up and collect within the blood vessels, inevitably making them narrower. As expected, the closer the blood vessels are, the less blood flow can travel through them and reach the femoral head. Again, once this blood supply reduces enough, the bone begins to undergo necrosis (die).

Other known causes are the following diseases:

  • Gaucher’s Disease
  • Diabetes
  • HIV/AIDS
  • Sickle Cell Disease
  • Pancreatitis
  • Chemotherapy/radiation therapy
  • Autoimmune deficiencies/diseases
  • Hypertension
  • Vasculitis
  • Caisson Disease

What are the Symptoms of Avascular Necrosis?

Avascular necrosis requires time for its onset. It is relatively asymptomatic to begin, but as it progresses, the pain becomes more pronounced. Pain limited hip range of motion is the main symptom both passively and actively, which can refer to pain down the length of the leg. Generally, the pain will arise when you place pressure on the bone, which unfortunately includes walking around!

Avascular Necrosis can often mask itself as other conditions in the early phase given its general pain presentation within the hip. Therefore, it is paramount for your health practitioner to record a detailed history of your clinical presentation. And perform a thorough examination to identify if avascular necrosis is your actual cause of pain.

How is Avascular Necrosis Diagnosed?

Avascular Necrosis can often mask itself as other conditions. Once other causes are excluded, and avascular necrosis is looking like the culprit, the gold standard for diagnosis is the imaging of the hip. Although MRI has proven to be the most accurate in diagnosis, researchers and radiographers have proposed a classification system based on plain x-rays known as the Ficat system.

Other scans are less useful and are more specific to certain stages of the injury, such as a bone scan or CT scan. The MRI can be used as a diagnostic tool and also as a means to monitor the remodelling/healing.

Avascular Necrosis Treatment

Conservative treatment with physiotherapy has proven to be relatively ineffective for avascular necrosis. Although conventional treatment aims to decrease the weight-bearing load through the head of the femur (usually by implementing crutches), research has shown that the condition still progresses in 1-2 years. Without definitive treatment, 70% to 80% of all avascular necrosis of the femoral head cases will progress and inevitably undergo surgery.

Irrespective of specific surgery, the primary goal is always to preserve the natural femoral head as opposed to replacing it.

There have been nonoperative treatments options proposed. You implement these before the femoral head collapse. They are, however, still in the early stages of research and development. Trials for the use of various electromagnetic, acoustic stimulation or pharmaceutical modalities have varying success. One of the most well known and successful early treatments is core decompression – i.e. decrease the pressure inside the femoral head. This decompression is achieved through drilling holes into the femoral head to create channels for new blood vessels to nourish the affected areas of the hip or the drill canals fill with healthy bone from another part of the body. This technique has proven to be successful; especially in those with early stages, avascular necrosis based on preoperative and postoperative MRI studies.

As evident, there is a multitude of different approaches utilised to manage avascular necrosis. Ultimately, an orthopaedic opinion is paramount to ensure treatment is as effective as possible. The decision as to which treatment to select will depend on the stage the avascular necrosis in combination with the clinical evaluation of the patient.

Please seek the advice of your hip physiotherapist or doctor for specific information.

Hip Pain Treatment

A thorough analysis of WHY you are suffering hip pain from a movement, posture, or a control aspect, is vital to solving your hip pain.

Only an accurate diagnosis of the source of your hip pain can solve the pain, quickly improve your day to day function, prevent a future recurrence,  or improve your athletic performance.

The first choice of short-term therapy has been symptomatic hip treatment. This approach could include local chemical modalities such as cortisone injections or painkillers. Ice or heat could also assist with some gentle stretching or exercise.

However, persisting hip problems will require additional investigations to assess your joint integrity or range of motion, muscle length, strength, endurance, power, contraction timing and dynamic stability control.

You should consult a healthcare practitioner who has a particular interest in hip pain and injury management to thoroughly assess your hip, groin, pelvis, lower limb and spine. Due to the kinetic chain, they all impact, especially at the high athletic performance end. A quality practitioner will educate you on your condition and combine it with exercise and manual therapy as per the Clinical Practice Guidelines. (Cibulka et al., 2017) Hip pain education should also include specific activity modification, individualised exercises, weight-loss advice (if required), and methods to unload any arthritic joints.

Recent research evidence-backed approaches have modernised physiotherapy treatment approaches to effectively managing hip pain. With a thorough hip assessment, your hip treatment can progress quickly to restore you to a pain-free hip and perform your regular sport or daily activities in the shortest time possible.

For specific rehabilitation advice regarding your hip pain, seek the professional advice of high quality and up-to-date physiotherapists experienced in the assessment, treatment, prevention and optimisation of hip pain and related conditions. After assessing you, they will individually prescribe therapeutic activities based on your specific needs for daily living, values, and functional activities or point you toward the most suitable healthcare practitioner for you and your hip condition.

Hip Pain Treatment Options

Your hip physiotherapist may consider an extensive range of treatment options, including manual joint therapy to improve your joint mobility, muscle stretches or supportive taping. Your physiotherapist is also likely to add strengthening and hip joint control exercises as they deem appropriate for your specific functional and sporting needs. Please consult with them for advice.

Hip Pain Info

Article by Zoe Russell

How Do You Diagnose Arthritis In The Hip?

Hip osteoarthritis is a progressive degenerative condition that results in pain, joint weakness, instability and restrictions of movement that interfere with daily activities, such as walking, climbing stairs or driving.

Your physiotherapist can diagnose hip osteoarthritis clinically through your subjective reporting. Symptoms may develop suddenly or gradually progress over time. Common symptoms include:

  • Hip joint pain or tenderness that comes and goes.
  • Typically there will be sharper pains in the groin and sometimes an ache in the front of the thigh. Many people present with hip arthritis thinking that it is a knee problem.
  • Hip stiffness, particularly in the mornings.
  • Limping when walking
  • Inability to stand on one leg without pain. For example, putting on underpants or clothes
  • Hip joint movements are restricted, especially inward rotation and hip flexion.
  • Weak hip muscles, especially during sit to stand, squatting and stair climbing.

This helps direct your PhysioWorks physiotherapist to perform physical tests to confirm the suspicion of osteoarthritis and to exclude other conditions that may present similarly:

Standard tests used to diagnose hip osteoarthritis include:

Range of Motion Testing

  • Performed in all planes of motion of the hip, this is helpful to see how much range of motion is available and if this is sufficient to perform your daily activities. This will also include assessing whether your movement is limited by lack of range or your pain.

Muscle Strength Testing

  • It is complementary to your range of motion testing to assess enough strength to support the painful joint.
  • There is good evidence to show that strengthening the muscles around the hip can improve symptoms and reduce the disability associated with a painful hip. Knowing which direction to enhance it is a crucial element to the assessment.

Functional Assessment

  • This is a crucial element to your assessment to identify your inability to perform daily activities due to your hip osteoarthritis and help guide your treatment.

Assessment of Adjacent Joints and Muscles

    • To ensure that your symptoms are only coming from your hip, your physiotherapist may assess other joints such as your Lower Back and SIJ to ensure that they are not the cause or contributing to your symptoms.

If hip osteoarthritis is suspected from your assessment, your physiotherapist may also request a hip radiograph or X-Ray to confirm the diagnosis.  In some cases, you may require further 3D imaging with CT or MRI to plan adjunct therapies or surgical replacement of the hip.

If you are concerned that your hip pain may be related to osteoarthritis, call PhysioWorks today. With same-day appointments, their expert staff can assess your hip pain and put a plan in place to help you get back to your best!

Hip Pain Info

Article by John Miller

Common Youth Leg Injuries

Why are Children's Injuries Different to Adults?

youth sports injuries

Adolescent Leg Injuries

Adolescent injuries differ from adult injuries, mainly because the bones are still growing. The growth plates (physis) are cartilaginous (strong connective tissue) areas from which the bones elongate or enlarge. Repetitive stress or sudden large forces can cause injury to these areas.

In the adolescent leg, common injuries include:

Osgood-Schlatter's Disease

Pain at the bump just below the knee cap (tibia tubercle). Overuse injuries commonly occur here. The tibia tubercle is the anchor point of your mighty quadriceps (thigh) muscles. Because of excessive participation in running and jumping sports, the tendon pulls bone off and forms a painful lump that will remain forever. This type of injury responds to reduced activity and physiotherapy.

More info: Osgood Schlatter's Disease

Sinding-Larsen-Johansson Disease

Pain at the lower pole of the knee cap (patella). Overstraining causes Sinding-Larsen-Johansson disease. Because of excessive participation in running and jumping sports, the tendon pulls bone off the knee cap. This type of injury responds to reduced activity and physiotherapy.

More info: Sinding Larsen Johansson Syndrome

Anterior Knee Pain

Anterior knee pain or patellofemoral syndrome frequently gets passed off as growing pains. Cause of this pain includes overuse, muscle imbalance, poor flexibility, poor alignment, or more commonly, a combination of these. Anterior knee pain is one of the most challenging adolescent knee injuries to sort out and treat. Accurate diagnosis and treatment with the assistance of a physiotherapist with a particular interest in this problem usually resolves the condition quickly.

More info: Patellofemoral Pain Syndrome

Knee Ligaments

The cartilage between the leg bones has a better blood supply and is more elastic in adolescents than adults. As adolescents near the end of bone growth, their injuries become more adult-like. Hence more meniscal and ACL (anterior cruciate ligament) injuries are likely. MCL (medial collateral ligament) injuries result from a lateral blow to the knee. Pain felt on the inner side (medially) of the knee. MCL injuries respond well to protective bracing and conservative treatment.

More info: Knee Ligament Injuries

ACL (Anterior Cruciate Ligament) Injuries

This traumatic knee injury is significant. Non-contact injuries of the ACL are becoming more common than contact injuries of the ACL. Adolescent females are at high risk. Combination injuries with MCL or menisci are common. Surgical reconstruction is needed if the adolescent wishes to continue participating in "stop-and-start" sports.

More info: ACL Injury

Meniscal Injuries

Your meniscus is crescent-shaped cartilage between the thigh (femur) and lower leg (tibia). Meniscal injuries usually result from twisting. Swelling, catching, and locking of the knee are common. If physiotherapy treatment does not resolve these damages within six weeks, they may require arthroscopic surgery.

More info: Meniscus Tear, Discoid Meniscus

Sever's Disease

Heel pain is commonplace in young adolescents due to the stresses of their Achilles tendon pulling upon its bony insertion point on the heel (calcaneum). It is a common overuse injury due to excessive training and competition, particularly when loads are increased dramatically in a short period. Diminished flexibility and muscle-tendon strength mismatching may predispose you. Physiotherapy, reduced activity, taping and orthotics are the best ways to manage this debilitating condition for the active young athlete.

More info: Sever's Disease

Ankle Sprain

An ankle sprain is probably the most common injury seen in sports. Ankles sprains involve stretching of the ligaments and usually occur when the foot twists inward. Treatment includes active rest, ice, compression and physiotherapy rehabilitation. With the correct treatment, a low ankle sprain usually improves in two to six weeks. Your ankle physiotherapist should check even simple ankle sprains to eliminate high-ankle sprains. A residually stiff ankle post-sprain can predispose you to several other lower limb issues.

More info: Sprained Ankle

Patellar Instability

Patellar (kneecap) instability can range from partial dislocation (subluxation) to dislocation with a fracture. Partial dislocation treatment is conservative. Dislocation with or without fracture is a much more severe injury and usually will require surgery.

More info: Patella Dislocation

Osteochondritis Dissecans

The separation of a bone from its bed in the knee joint is Osteochondritis Dissecans (OCD). This injury is usually due to one major macro event with repetitive macro trauma that prevents complete healing. This injury is potentially severe. Treatment varies from rest to surgery. An Orthopaedic Surgeon's opinion is vital.

More info: Juvenile Osteochondritis Dissecans (JOCD)

Growth Plate Fractures

A fracture through the growth plate can be a severe injury that can stop the bone from growing correctly. These fractures should be treated by an Orthopaedic Surgeon, as some will require surgery.

Avulsion Fractures

youth pelvis hip avulsion

Image source: https://radiologyassistant.nl/pediatrics/hip/hip-pathology-in-children

An avulsion fracture occurs when a small segment of bone attached to a tendon or ligament gets pulled away from the main bone. The hip, elbow, and ankle are the most common locations for lower limb avulsion fractures in young sportspeople.

Treatment of an avulsion fracture typically includes active rest, ice and protecting the affected area. This active rest period is followed by controlled exercises that help restore range of motion, improve muscle strength and promote bone healing. Your physiotherapist should supervise your post-avulsion exercises. Most avulsion fractures heal very well.  You may need to spend a few weeks on crutches if you have an avulsion fracture around your hip. An avulsion fracture to your foot or ankle may require a cast or walking boot.

An excessive gap between the avulsed bone fragment and main bone may not rejoin naturally in rare cases. Surgery may be necessary to reunite them. In children, avulsion fractures that involve the growth plates also might require surgery. All avulsion fractures should be reviewed and managed by your trusted physiotherapist or an Orthopaedic Surgeon.

For more information regarding your youth sports injury, please consult your physiotherapist or doctor.

Youth Leg Injuries

Pelvis & Hip

Knee

Heel & Ankle

Common Youth & Teenager Sports Injuries

Common Youth Neck & Back Pain

Common Youth Arm Injuries

Acute Injury Signs

Acute Injury Management.

Here are some warning signs that you have an injury. While some injuries are immediately evident, others can creep up slowly and progressively get worse. If you don't pay attention to both types of injuries, chronic problems can develop.

For detailed information on specific injuries, check out the injury by body part section.

Don't Ignore these Injury Warning Signs

Joint Pain

Joint pain, particularly in the knee, ankle, elbow, and wrist joints, should never be ignored. Because these joints are not covered by muscle, pain here is rarely of muscular origin. Joint pain that lasts more than 48 hours requires a professional diagnosis.

Tenderness

If you can elicit pain at a specific point in a bone, muscle, or joint, you may have a significant injury by pressing your finger into it. If the same spot on the other side of the body does not produce the same pain, you should probably see your health professional.  

Swelling

Nearly all sports or musculoskeletal injuries cause swelling. Swelling is usually quite obvious and can be seen, but occasionally you may feel as though something is swollen or "full" even though it looks normal. Swelling usually goes along with pain, redness and heat.

Reduced Range of Motion

If the swelling isn't obvious, you can usually find it by checking for a reduced range of motion in a joint. If there is significant swelling within a joint, you will lose range of motion. Compare one side of the body with the other to identify major differences. If there are any, you probably have an injury that needs attention.

Weakness

Compare sides for weakness by performing the same task. One way to tell is to lift the same weight with the right and left sides and look at the result. Or try to place body weight on one leg and then the other. A difference in your ability to support your weight is another suggestion of an injury that requires attention.

Immediate Injury Treatment: Step-by-Step Guidelines

  • Stop the activity immediately.
  • Wrap the injured part in a compression bandage.
  • Apply ice to the injured part (use a bag of crushed ice or a bag of frozen vegetables).
  • Elevate the injured part to reduce swelling.
  • Consult your health practitioner for a proper diagnosis of any serious injury.
  • Rehabilitate your injury under professional guidance.
  • Seek a second opinion if you are not improving.

Article by John Miller

Elite Sports Injury Management

You probably already know that a sports injury can affect not only your performance but also your lifestyle. The latest research continues to change sports injury management considerably.  Our challenge is to keep up to date with the latest research and put them to work for you.

How we treated you last year could vary significantly from how we treat you this year. The good news is that you can benefit considerably from our professional knowledge.

What Should You Do When You Suffer a Sports Injury?

Rest?

Rest from painful exercise or a movement is essential in the early injury stage. "No pain. No gain." does not apply in most cases.  The rule of thumb is - don't do anything that reproduces your pain for the initial two or three days.  After that, you need to get it moving, or other problems will develop.

Ice or Heat?

We usually recommend avoiding heat (and heat rubs) in the first 48 hours of injury. The heat encourages bleeding, which could be detrimental if used too early. In traumatic injuries, such as ligament sprains, muscle tears or bruising, ice should help reduce your pain and swelling.

Once the "heat" has come out of your injury, you can use heat packs. We recommend 20-minute applications a few times a day to increase the blood flow and hasten your healing rate. The heat will also help your muscles relax and ease your pain. If you're not sure what to do, please call us to discuss your situation specifically.

Should You Use a Compressive Bandage?

Yes. A compressive bandage will help to control swelling and bleeding in the first few days.  In most cases, the compressive dressing will also help support the injury as you lay down the new scar tissue. This early healing should help to reduce your pain. Some injuries will benefit from more rigid support, such as a brace or strapping tape. Would you please ask us if you are uncertain about what to do next?

Elevation?

Gravity will encourage swelling to settle at the lowest point.  Elevation of an injury in the first few days is beneficial, especially for ankle or hand injuries.  Think where your damage is and where your heart is. Try to rest your injury above your heart.

What Medication Should You Use?

Your Doctor or Pharmacist may recommend pain killers or an anti-inflammatory drug. It is best to seek professional advice as certain medications can interfere with other health conditions, especially asthmatics.

When Should You Commence Physio?

sports injury

In most cases, "the early bird gets the worm".  Researchers have found that the intervention of physiotherapy treatment within a few days has many benefits.  These include:

  • Relieving your pain quicker via joint mobility techniques, massage and electrotherapy
  • Improving your scar tissue using techniques to guide the direction it forms
  • Getting you back to sport or work quicker through faster healing rates
  • Loosening or strengthening of your injured region with individually prescribed exercises
  • Improving your performance when you return to sport - we'll detect and help you correct any biomechanical faults that may affect your technique or predispose you to injury.

What If You Do Nothing?

Research tells us that injuries left untreated take longer to heal and have lingering pain.  They are also more likely to recur and leave you with either joint stiffness or muscle weakness. It's important to remember that symptoms lasting longer than three months become habitual and are much harder to solve.  The sooner you get on top of your symptoms, the better your outcome.

What About Arthritis?

Previously injured joints can prematurely become arthritic through neglect. Generally, there are four main reasons why you develop arthritis:

  • An inappropriately treated previous injury (e.g. old joint or ligament sprains)
  • Poor joint positioning (biomechanical faults)
  • Stiff joints (lack of movement diminishes joint nutrition)
  • Loose joints (excessive sloppiness causes joint damage through poor control)

What About Your Return to Sport?

Your physiotherapist will guide you safely back to the level of sport at which you wish to participate.  If you need guidance, ask us.

What If You Need Surgery or X-rays?

Not only will your physio diagnose your sports injury and give you the "peace of mind" associated, but they'll also refer you elsewhere if that's what's best for you. Think about it. You could be suffering needlessly from a sports injury.  Would you please use our advice to guide you out of pain quicker? And for a lot longer.

If you have any questions regarding your sports injury (or any other condition), don't hesitate to get in touch with your physiotherapist to discuss. You'll find our friendly staff happy to point you in the right direction.

Acute Sports Injury Clinic

How to Best Care for Your Sports Injury?

There is never an excellent time for an injury. But we do know that most sports injuries occur over the weekend! That's why at PhysioWorks, we have established an Acute Sports Injury Clinic at a selection of our clinics on a Monday and Tuesday.

PhysioWorks has established an Acute Sports Injury Clinic at our Ashgrove, Clayfield and Sandgate practices to assist with the early assessment and management of acutely injured sports injuries.

The acute sports injury consultation fee is significantly lower than a routine assessment and treatment consultation. In most cases, your private health will cover the full cost of your full acute injury physio assessment fee.

Why Use an Acute Sports Injury Clinic?

Your Acute Sports Injury Assessment Consultation allows us to provide you with:

  • A quick and accurate diagnosis. One of our Sports Physiotherapist's or an experienced sports injury-focused Physiotherapist will confidently guide your new injury management.
  • Early acute sports injury care, professional advice and education. What to do this week?
  • Fast referral for X-rays, ultrasound or MRI scans to confirm your diagnosis.
  • Prompt referral to Sports Physicians, GPs or Surgeons with whom we work if required.
  • Immediate supply of walking boots, braces and rental crutches if needed.
  • Low-cost professional service.

More Information

For more friendly advice or guidance, please call your nearest clinic to discuss your specific needs.

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