12/9/2013 Diagnosis and Treatment of Hip Pain in the Athlete History Was there an injury? Pain Duration Location Type Better/Worse Severity Subjective Jonathan M. Fallon, D.O., M.S. assessment Shoulder Surgery and Operative Sports Medicine Sports www.hamportho.com Hip and Groin Pain Location, Location , Location 1. Inguinal Region • Diagnosis difficult and 2. Peri-Trochanteric confusing Compartment • Extensive rehabilitation • Significant risk for time loss 3. Mid-line/abdominal Structures • 5‐9% of sports injuries 3 • Literature extensive but often contradictory 1 • Consider: 2 – Bone – Soft tissue – Intra‐articular pathology Differential Diagnosis Orthopaedic Etiology Non‐Orthopaedic Etiology Adductor strain Inguinal hernia Rectus femoris strain Femoral hernia Physical Examination Iliopsoas strain Peritoneal hernia Rectus abdominus strain Testicular neoplasm Gait Muscle contusion Ureteral colic Avulsion fracture Prostatitis Abdominal Exam Gracilis syndrome Epididymitis Spine Exam Athletic hernia Urethritis/UTI Osteitis pubis Hydrocele/varicocele Knee Exam Hip DJD Ovarian cyst SCFE PID Limb Lengths AVN Endometriosis Stress fracture Colorectal neoplasm Labral tear IBD Lumbar radiculopathy Diverticulitis Ilioinguinal neuropathy Obturator neuropathy Bony/soft tissue neoplasm Seronegative spondyloarthropathy 1 12/9/2013 Physical Examination • Point of maximal tenderness Athletic Pubalgia – Psoas, troch, pub sym, adductor – Gilmore’s groin (Gilmore • C sign • ROM 1992) • Thomas Test: flexion contracture – Sportsman’s hernia • McCarthy Test: labral pathology (Malycha 1992) • Impingement Test – Incipient hernia 3 • Clicking: psoas vs labrum • Resisted SLR: intra‐articular – Hockey Groin Syndrome – • Ober: IT band Slapshot Gut • FABER: SI joint – Ashby’s inguinal ligament • Heel Strike: Femoral neck • Log Roll: intra‐articular enthesopathy • Single leg stance –Trendel. Location, Location , Location Athletic Pubalgia - Natural History 1. Inguinal Pain – Intra-articular -Femoroacetabular Impingment Disabling lower abdominal/inguinal pain at extremes -Flexor Strain of exertion -Hernia Pain at rectus insertion, progresses despite treatment Pain abates with cessation of activity 2. Peri-Trochanteric Compartment 3 Hyperextension injury with a hyper‐abduction of the -Trochanteric Bursitis 1 thigh -Piriformis Syndrome 2 Male predominant injury 3. Mid-Line Structures -Ramus Fx, Osteitis Pubis -Athletic Pubalgia, Hernia Athletic Pubalgia Midline Pain ‐ Anatomy Meyers et al AJOSM Viscera ‘00 Bony Architecture Chronic inguinal or Muscle layers pubic area pain Noted on exertion only 3 dDx: Not explainable by a Athletic Pubalgia palpable hernias Osteitis Pubis Not explainable by Stress fracture other medical Tendonitis diagnosis 2 12/9/2013 Physical Exam Inguinal “Hip” Pain Tender to Palpation over Peripubic Area, Symphysis 1. Hernia Pubis, or Adductor Area 2. AVN No Palpable Hernia 3. Internal Snapping Hip 4. Intra-articular Snapping Hip Pain with Resisted Adduction •Loose Bodies or Situps •Synovial Chondromatosis 1 •Lesions of the Ligamentum Teres Tight Hamstrings or Limited •Labral Tear Hip Motion 5. Femoral-Acetabular Impingement Neuro Exam Normal Osteitis Pubis Inguinal & Femoral Hernias Inflammatory Process of Symphysis Inguinal Hernia Femoral Hernia Persistent Processus Under Inguinal Ligament, in Microtrauma from Athletic Activity Vaginalis Space Medial to the Femoral Kicking and Running Groin Pain Radiating to Vein in the Femoral Triangle Occurs in: Upper Thigh Long Distance Runners Worse with Valsalva Tender to Palpation and Mass can be Felt Soccer Players Weight Lifters Diffrential Diagnosis: Diagnosis Requires High Fencers Epididymitis Scrotal Abscess Index of Suspicion Football Players Testicular Torsion Imbalance Abdominals and Hip Adductors Varicocele Open Surgical Repair Pain with passive abduction and resisted Spermatocele adduction Hydrocele Surgical Repair Often Insidious but Can Be Acute Endoscopic vs. Open Pelvic Stress Fractures Repetitive Motion such as Running Avascular Necrosis Pain Subsides with Rest Etiology Rami Trauma No Limitation in Hip Motion Pain Standing Unsupported on Sickle Cell Affected Leg (Positive Standing Sign) Steroids Sacrum Distance runners Binge Drinking Pain with Weight Bearing Idiopathic Femoral Neck Limited Internal Rotation of Hip Can Be Bilateral (IMAGE BOTH SIDES) AVN is the final common pathway 3 12/9/2013 Avascular Necrosis FAI Presentation Physical exam Insidious Onset Limited flexion • Impingement Sign Activity Related • Pain when maximally flexed and internally rotated Progressive • 87% sensitivity • McCarthy’s Sign • Pain with full extension of a flexed and externally rotated hip • Anterior labrum (82% sensitivity) Loose Bodies / Synovial Chondromatosis Impingement Mechanism Multiple Causes: Dislocation Synovial Chondromatosis OCD Catching pain Sharp Locking Femoroacetabular Impingement Labral Tear • Pain with repetitive twisting History and strenuous pivoting Sharp groin pain, • Impingement Sign Exacerbated with flexion – Pain when maximally flexed activities and internally rotated – Postero/supero labrum (87% Catching sensitivity) “C” Sign • McCarthy’s Sign Radiate to buttock or thigh – Pain with full extension of a History of intermittent flexed and externally rotated hip groin strain – Anterior labrum (82% sensitivity) 4 12/9/2013 Peritrochanteric/Buttock “Hip Open vs. Arthroscopic Treatment Pain” • Burnese experience Trochanteric Bursitis – Open dislocation with External Snapping Hip osteoplasty Gluteus Medius – Long term results show minimal change Tendinosis/ Tears in outcome Piriformis Pain • Arthroscopic – Minimally invasive – Takedown and repair possible Ruptured Ligamentum Teres Bursitis Occurs from Repetitive Friction with History of injury Nearby Muscle or Traumatic Injury to Pain with flexion and Surrounding Tissue internal rotation Can Be Difficult to Differentiate from MRI Arthrography other Soft Tissue Processes may show lesion in e.g. Contusion or Strain fossa Several (13) Bursa About Hip Four Major Bursa Trochanteric Bursa Ischial Bursa Iliopectineal Bursa Iliopsoas Bursa Tumor Pelvic/Hip Bursitis • Trochanteric Should always be – Friction of IT band over Gr. Troch. considered – Localized by ER and adduction Night pain, rest pain • Ischial Constitutional – Common in Hockey and Skaters – Exacerbated by Sitting symptoms • Illiopsoas Mets, Primary Tumor, – Anterior Snapping Hip PVNS • Illiopectineal – Continuance of Illiopsoas bursa – Irritation of Illiopsoas tendon over IP eminence 5 12/9/2013 Snapping Hip Syndrome Coxa Saltans Arthroscopic Bursectomy and External is most common Tendon Repair ITB or Gluteus Maximus Sliding Over Occur in Active Late For recalcitrant Bursitis Trochanter Teens and 20’s Lengthening of IT Inflammation of the Trochanteric band Bursa Debridement or Internal Repair of Abductors Iliopsoas Snaps over Iliopectineal Eminence or Femoral Head Intra‐articular Labral Tears, Loose Bodies, Osteochondral Injury Often History of Trauma Gluteus Medius Tear Other “Hip Pain •Late‐Middle age (F>M) •Tendinosis (similar to Rotator Cuff) •Possible cause of recalcitrant Bursitis Muscle Strains and Tendonitis Gluteus Medius Tear Cause Symptoms: Violent Eccentric Contraction Postero‐medial Pain with Muscle on Stretch Contused Muscle is Susceptible Sitting and transitional to Strain Injury pain May also develop from Activity related Microtrauma Exam Trendelenburg Sign Muscles that Cross 2 Joints Isolated Weakness are More Susceptible to Strain 45’ hip flexion Adductor Longus Rectus Femoris External Oblique 6 12/9/2013 Myositis Ossificans • Occurs In: Avulsion Fractures – Areas of Deep Soft Tissue Injury with Hematoma Skeletally immature athletes – Around a Joint or Tendon Insertion / Origin Failure at apophysis ASIS • Presents as Painful Mass AIIS Associated with Loss of Iliac Crest Motion Greater Trochanter Lesser Trochanter • Radiographs Lag Behind Ischial Tuberosity Larson, et al. Evaluating and Managing Muscle • Treatment is based on Contusions and Myositis Ossificans. Phys Sport Med. clinical findings Vol 30 / No 2: Feb, 2002. Apophysitis • Can Occur Anywhere in Hip Girdle Nerve Entrapment Syndromes – Iliac Crest Most Likely Sciatic Piriformis Syndrome • Overuse phenomenon – Similar to Other Apophysites Obturator Pudendal • Diagnosis by Clinical Exam – Tender to Palpation over Area Ilioinguinal Femoral • Radiographs Show Physeal Widening if Chronic Lateral Femoral Cutaneous Nerve McCrory & Bell. Nerve Entrapment Syndromes as a Cause of Pain in the Hip, Groin and Buttock. Sports Med 1999 Apr; 27 (4): 261- • Treat by Modifying Offending 274. Activities Until Discomfort Subsides Contusions Most Common Athletic Hip Treatment Overview Injury Physical Therapy Imaging Usually Collision with Another 1st Line Treatment Xray Player, Equipment Collision or Range of Motion MR Arthrogram Fall to Surface US/Deep Tissue CT (3‐D recon) release US –user dependant Can Occur Over Bony Graston Technique Cortisone Injection Prominences: Core/Hip Strength Diagnostic and Iliac Crest –“Hip Pointer” theraputic Greater Trochanter Ischial tuberosity 7 12/9/2013 Questions Surgical Treatment • A 25 Year Old Professional Hockey Player is Referred to Your Office by the Team Trainer After 6 Weeks of Physical After all else fails… Therapy Failed to Improve His Symptoms. X-Rays and MRI Open vs Arthroscopic of