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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
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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
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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
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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)
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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
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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
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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
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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 the Pelvis Were Normal. He Complains of Diffuse Groin and Lower Abdominal Pain Which Increases with Heavy Weight Training. Exam Reveals Bilateral Adductor Tightness but NO Pubic or Adductor Tenderness. What is the BEST Next Step in Management of this Patient?
• A) Bone Scan • B) Referral to a Surgeon • C) Decreased Weight Training • D) Administer a Corticosteroid Injection • E) CT Scan of the Pelvis Sports Medicine Self Assessment Examination. American Academy of Orthopaedic Surgery. 2004
Thank You ‐ Any Questions? Questions E) Referral to an Orthopaedic or General Surgeon
This is a case of a sports hernia and must be differentiated from other hernias. This can be diagnosed by an orthopaedist, but a general surgeon is best suited to ultimately manage this condition.
Jonathan M. Fallon, D.O., M.S. www.hamportho.com [email protected]
413‐586‐8200 Sports Medicine Self Assessment Examination. American Academy of Orthopaedic Surgery. 2004
Questions Questions • A 25 Year Old Professional Hockey Player is Referred to Your Office by the Team Trainer After 6 Weeks of Physical • A 24 Year Old Professional Squash Player Presents with Therapy Failed to Improve His Symptoms. X-Rays and MRI Persistent Right Inguinal Pain and Clicking After an of the Pelvis Were Normal. He Complains of Diffuse Groin Episode of Lunging for a Backhand. A Plain Radiograph and Lower Abdominal Pain Which Increases with Heavy is Unremarkable. MR Arthrogram reveals a Labral Tear. Weight Training. Exam Reveals Bilateral Adductor Tightness He Has Failed to Respond to a 3 Month Course of Rest, but NO Pubic or Adductor Tenderness. What is the BEST Stretching and NSAIDs. Which is the Most Appropriate Next Step in Management of this Patient? Treatment Plan?
• A) Bone Scan • A) Hip Arthroscopy and Debridement • B) Referral to a General Surgeon • B) Arthrotomy and Repair • C) Decreased Weight Training • C) Right Inguinal Herniorrhaphy • D) Administer a Corticosteroid Injection • D) Electromyography • E) CT Scan of the Pelvis • E) CT Guided Needle Biopsy Sports Medicine Self Assessment Examination. Review Questions in Orthpaedics. American Academy of Orthopaedic Surgery. 2004 Wright, et al., Lippincott, Williams and Wilkins. 2002
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Questions Questions A 24 Year Old Professional Squash Player Presents with Which of the Following Best Describes Athletic Pubalgia? Persistent Right Inguinal Pain and Clicking After an Episode of Lunging for a Backhand. A Plain Radiograph is Unremarkable. MRI Reveals a Labral Tear. He Has Failed to A) A Syndrome of Lower Abdominal and Adductor Pain Respond to a 3 Month Course of Rest, Stretching and B) Painful Symptoms Emanating from the Symphysis Pubis NSAIDs. Which is the Most Appropriate Treatment Plan? C) Painful Symptoms Associated with Dysfunction of the Iliopsoas Tendon A) Hip Arthroscopy and Debridement D) Stress Fracture of the Pubic Ramus B) Arthrotomy and Repair E) Entrapment of the Pudental Nerve C) Right Inguinal Herniorrhaphy D) Electromyography E) CT Guided Needle Biopsy Review Questions in Orthpaedics. Sports Medicine Self Assessment Examination. Wright, et al., Lippincott, Williams and Wilkins. 2002 American Academy of Orthopaedic Surgery. 2004
Questions Questions A) A Syndrome of Lower Abdominal and Adductor Pain A) Hip Arthroscopy and Debridement
Athletic pubalgia is a distinct syndrome of lower abdominal Labral tears typically affect the anterosuperior portion of the and adductor pain that is most commonly seen in high acetabulum rim. They are more common in the presence of performance male athletes. This condition must be acetabular dysplasia. After lack of response to an adequate distinguished from others such as painful inflammation of the course of conservative management, arthroscopic evaluation symphasis pubis, referred to as osteitis pubis and “snapping and debridement of the involved portion of the labrum are hip” symptoms attributable to the iliopsoas tendon. appropriate.
Review Questions in Orthpaedics. Sports Medicine Self Assessment Examination. Wright, et al., Lippincott, Williams and Wilkins. 2002 American Academy of Orthopaedic Surgery. 2004
Questions Questions Which of the Following Best Describes Athletic Pubalgia? A 16 year old female lacrosse player complains of audible popping and pain in her hip when she runs. Physical exam demonstrates mild pain with resisted hip flexion. A click can A) A Syndrome of Lower Abdominal and Adductor Pain be elicted with hip adduction with the knee in extension. B) Painful Symptoms Emanating from the Symphysis Pubis C) Painful Symptoms Associated with Dysfunction of the The location of the pathology is most likely to be: Iliopsoas Tendon A. Intra articular D) Stress Fracture of the Pubic Ramus B. Between the IT band and the greater trochanter E) Entrapment of the Pudental Nerve C. Between the iliopsoas muscle and the anterior hip capsule D. Near the adductor longus origin E. Between the rectus femoris and anterior hip capsule
Sports Medicine Self Assessment Examination. AOSSM Self Assessment and Board Review. Version 2. American Academy of Orthopaedic Surgery. 2004 American Orthopaedic Society for Sports Medicine. 2006
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Questions A 16 year old female lacrosse player complains of audible popping and pain in her hip when she runs. Physical exam demonstrates mild pain with resisted hip flexion. A click can be elicted with hip adduction with the knee in extension.
The location of the pathology is most likely to be: A. Intra articular B. Between the IT band and the greater trochanter C. Between the iliopsoas muscle and the anterior hip capsule D. Near the adductor longus origin E. Between the rectus femoris and anterior hip capsule
AOSSM Self Assessment and Board Review. Version 2. American Orthopaedic Society for Sports Medicine. 2006
Questions B. Between the IT band and the greater trochanter
The most common type of “snapping hip” is external which occurs between the iliotibial band and the greater trochanter. Other types of snapping hip include the internal type, which is most commonly seen in ballet dancers. The internal type occurs between the iliopsoas tendon and the anterior hip capsule. A snapping hip can also be caused by intra-articular pathology including loose bodies and labral tears.
AOSSM Self Assessment and Board Review. Version 2. American Orthopaedic Society for Sports Medicine. 2006
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