SportsMedToday.com YOUR COMPREHENSIVE SPORTS MEDICINE RESOURCE FOR ATHLETES, COACHES AND PARENTS Trochanteric Pain Syndrome SPRING 2019 Shane Larson, MD Lateral hip pain is common in active individuals of various ages, sports and competition levels. One of the most common causes is greater trochanteric pain syndrome, also called “trochanteric bursitis.” However, recent studies using medical imaging1 show that the overlying potential space, known as a bursa, is rarely involved. These studies are also supported in tissue analysis done after surgery.2 This article highlights trochanteric pain syndrome, the underlying causes, treatment options, rehabilitation choices, and other causes of lateral hip pain. Trochanteric pain syndrome typically appears with lateral hip pain around the greater trochanter, which is near the hip. Symptoms increase with activity or laying on the affected side. Feeling pain when it’s pressed on is a key to diagnosing it. A lack of tenderness probably means it’s another condition, including some other running mechanics.4 femoral-acetabular impingement (FAI), possibilities discussed below. Initial treatment consists of avoiding snapping hip and sacroiliitis. Other Greater trochanteric pain syndrome painful activities while dealing with conditions not discussed in this article is typically a chronic but self-limited biomechanical issues such as poor include traumatic injuries, referred pain condition behind overuse and poor running form. In addition, oral from the knee or ankle, and lower-back- running form or gait. This leads to medications such as acetaminophen or related pain. A detailed physical exam increased stress on the tendons that non-steroidal anti-inflammatory drugs and possibly use of imaging such as x-rays stabilize the pelvis and lower extremities. (NSAIDs) like ibuprofen, can be used and/or MRI may be necessary to rule out This eventually leads to the development for more severe pain. Tendinopathy is these conditions. of tendinopathy in these tendons. This best treated through directed exercises • Osteoarthritis of the hip: affects approximately 6-15% of patients (typically eccentric exercises), under Trochanteric pain syndrome is more 3 in some studies. Risk factors may the guidance of a physical therapist. common in those 50 to 70 years old, include female gender, obesity, chronic Strengthening of the muscles in the which is also a common age for hip back pain and injuries to the knee or same area have shown benefit as a osteoarthritis. Hip osteoarthritis typically ankle, likely secondary to changes in rehabilitation focus in recent studies5. happens with pain in front of the hip, but Doctors may also try a corticosteroid it can also occur with lateral or posterior injection if pain is limiting rehabilitation hip pain. It is diagnosed with x-rays. exercises or sleep. Newer, emerging • FAI: Younger patients may have injection therapies have been reported, FAI, which features pain in a C-shaped including the use of prolotherapy, pattern wrapping around their hip from platelet rich plasma, and other injections. back to front. Individuals with FAI have • Trochanteric Pain Syndrome But there is limited evidence with few bony changes to either the ball or socket long-term follow-ups reported, so further • Exertional Leg Pain of the hip joint on x-ray. This leads to research is necessary. impingement of the cartilage and labrum • Spondylolysis Not all lateral hip pain is due to and can lead to early osteoarthritis. trochanteric pain syndrome. Four of the • Snapping hip syndrome: Patients • Knee Osteochondritis Dissecans most common alternative problems are describe mechanical snapping to the discussed below, including osteoarthritis, continued on next page…

Resource courtesy of SportsMedToday.com. CONTINUED FROM PAGE 1 attributed to trochanteric bursitis, which 2. Silva F, Adams T, Feinstein J, et al. Trochanteric bursitis refuting the myth of inflammation. J front of the hip (internal) or lateral is now known as greater trochanteric Clin Rheumatol. 2008 Apr;14(2):82-6. hip (external). This comes from a tight pain syndrome. This overuse condition 3. Segal NA, Felson DT, Torner JC, et al. Greater iliopsoas tendon or lliotibial (IT) band is secondary to tendinopathy in the hip trochanteric pain syndrome: epidemiology and associated factors. Arch Phys Med Rehabil. respectively. muscles and treatments center on pain 2007 Aug;88(8):988-92. • acroiliitis: Typically happens with control, physical therapy and activity 4. Fearon AM, Scarvell JM, Neeman T, et al. posterior hip pain, but it can also cause modification. Greater trochanteric pain syndrome: defining the clinical syndrome. Br J Sports Med. 2013 groin or lateral hip pain. The diagnosis Jul;47(10):649-53 is typically made through physical exam REFERENCES 1. Bird PA, Oakley P, Shnier R, et al. Prospective 5. Mellor R, Bennell K, Grimaldi A, et al. Education and imaging, if necessary. evaluation of magnetic resonance imaging and plus exercise versus corticosteroid injection In summary, lateral hip pain is a physical examination findings in patients with use versus a wait and see approach on global greater trochanteric pain syndrome. Arthritis outcome and pain from gluteal tendinopathy: common condition in patients and often Rheumatism. 2001;44: 2138–2145 prospective, single blinded, randomised clinical trial. BMJ. 2018 May 2;361:k1662.

Exertional Leg Pain Jeff Fleming, DO Now that springtime is here, athletes femur, and compromised bone density. are moving from the comforts of indoor Unlike shin splints, athletes tend to have training facilities to the great outdoors. more pain that consistently gets worse The transition to the open air offers with activity. Treatment consists of rest both a change in scenery and in workout and activity modification, but requires routine. For many athletes, that means longer rest periods of six to nine weeks. longer and more intense training, as More severe cases may need longer well as new shoes for outdoor surfaces, recovery periods from six to 12 weeks. and not adapting to a new routine often This depends on the severity of the leads to injury. injury and the individual’s bone health and nutrition. Management can involve Exertional leg pain is a common crutches, casting or even surgery in complaint from athletes making this severe cases. seasonal transition. Exertional pain is often attributed to routine muscle A rare cause of exertional leg pain soreness, but what about pain that just is Chronic Exertional Compartment won’t go away on its own? This article Syndrome (CECS). This injury typically examines some common causes of happens in long distance and endurance exertional leg pain. runners. Experts think that overuse leads to increased pressure within the muscle right”, and typically changed every Shin Splints, or Medial Tibial Stress compartments of the lower legs. CECS 300-500 miles. Syndrome (MTSS), are typically caused pain is caused by exercise and often • Balance your nutrition intake with by repetitive stress and ramping up completely resolves with rest. Diagnosis your energy needs. If you have impact exercise too fast. Symptoms is made by measuring pressure following high volumes of training, you may include pain around the inner part of the exercise. It can often be managed want to seek advice of a sports shin. This pain can sometimes get better conservatively, but surgery is sometimes nutritionist. with activity, but it usually pops up again needed in severe cases. • Try not to run through severe after the workout and gets worse by the fatigue, as it can be a major next morning. Shin splints are a relatively Each of these injuries is likely related contributing factor to poor running benign injury and can usually be to a combination of over-training, technique. managed with rest, activity modification, inadequate recovery, imbalances and symptomatic relief. Athletes should between energy needs and food intake, When dealing with exertional leg pain, rest until they are pain-free with daily as well as improper running form. a trial of rest and activity modification is activities. This can take anywhere from The best treatment for any injury is almost always a good first step. However, two to six weeks depending on the prevention. When transitioning to high it’s important to be aware that leg pain injury. levels of speed, distance, or intensity, be can be caused by dozens of other injuries sure to do so safely. Gradually increase and diseases. Many of these are more Stress fracture, or Tibial Bone Stress the duration, volume, and intensity of serious than the injuries described Injury (TBSI), is another common workouts. above. Seek expert medical advice if source of exertional leg pain and can be symptoms do not improve within a few considered more severe. Stress fractures General guidelines to follow: days or suddenly get worse. An early can also be explained by a combination • Increase your distance by no more diagnosis can ensure that an athletes is of excess stress on the tibia, which is than 10-15% per week. assigned an appropriate treatment plan the second largest bone next to the • Shoes should be comfortable, “feel to prevent further injury. Spondylolysis Daisy Scarlett-MacCallum, MD

Spondylolysis is an overuse injury that causes a stress fracture to the area of the spine called the pars interarticularis. It is a relatively common cause of low back pain among adolescent athletes involved in sports that involve frequent back extension (1,2). Most injuries occur in the lower back (2). Spondylolisthesis occurs when both sides of the spine are involved, causing the vertebrae to slip forward on one another. This article looks at how to manage both of these conditions. It’s worth noting that there is limited evidence on the best non-surgical treatment of these issues, and even experts have differences in opinion. Treatment of spondylolysis and stable spondylolisthesis consists of resting from sport, avoidance of activities that might cause them and pain control with ice, heat and over-the-counter pain medications. Anyone suspected of to run, jump and normally extend their 2. Berger R., Doyle S. Spondylolysis 2019 Update. Current Opinion in Pediatrics. having spondylolysis based on history back without pain, in order to begin the 31(1):61-68. and physical examination are observed progress to normal sport activities. The 3. Randall RM, Silverstein M, Goodwin R. for two to four weeks and instructed to level of activity can then increase weekly Review of Pediatric Spondylolysis and (3-5) (8-9) Spondylolisthesis. Sports Med Arthosc Rev. stop all activities that might cause it . with more intense sport-specific play . 2-16 Dec;24(4): 184-187. If symptoms get better after this time, As the intensity of activities increases, 4. Miller R, Beck NA, Sampson NR, et. al. athletes can gradually return to sport. If doctors will follow-up with the patient Imaging modalities for low back pain in symptoms persist or the pain happens children: a review of spondylolysis and about every two weeks to check for undiagnosed mechanical back pain: J Pediatr again, they should be re-examined and returning symptoms. This continues until Orthop 2013; 33:282. medical imaging should be considered. the athlete returns to full participation 5. Chugh AJS., Alsonso F. et. al. Stable X-rays are typically a good option without pain (9). The main reasons why Spondylolisthesis: Should Management Change Based on Presence of Facet Cysts? for this, but MRI imaging is used in treatment is unsuccessful or prolonged Clin Spine Surg. 2019 Feb 22. Doi: 10.1097. youth athletes or if the doctor suspects is not following activity restrictions 6. Lee GW, Lee SM, Ahn MW, et. al. Comparison spondylolysis. Once it’s confirmed, a (1-3, 11). So it’s important that athletes of surgical treatment with direct repair versus conservative treatment in young patients with period of 90 days of rest with monthly and doctors have a straightforward spondylolysis: a prospective, comparative, follow-ups are recommended (6-7). conversation about the risks, and doctors clinical trial. Spine J 2015; 15:1545. Patients are to avoid all activities that should make sure that athletes, parents 7. Klein G, Mehlman CT, McCarty M. Nonoperative treatment of spondylolysis may aggravate pain, especially ones and coaches are all winning to cut back and grade I spondylolisthesis in children and that require back extension. Athletes on risky activities. young adults: a meta-analysis of observational can benefit from working with physical Despite the popularity of the Boston studies. J Pediatr Orthop 2009;29:146. 8. Bouras T, Korovessis P. Management of therapists and athletic trainers, as Back Brace, several studies have found spondylolysis and low grade spondylolisthesis they can give important guidance in good outcomes without bracing (7). in fine athletes. A comprehensive review. Eur. (9-10) J Orthop Surg Traumatol, 2015 Jul;25 Suppl determining the right rehabilitation . Patients may have difficulty following 1:S167-75. As exercises become easier, athletes can the recommended 23-hours a day in the 9. Iwamoto J, Sato Y, Takeda T, et. al. Return to slowly ramp up exercise difficulty (9-10). brace. In addition, time spent wearing a sports activity by athletes after treatment of The timeframe for return to play after brace may lead to weakening of muscles spondylolysis. World J Orthop 2010; 1:26. the rest period can change, but studies (7) 10. Standaert CJ, Herring SA. Expert opinion and in the back and torso . The decision to controversies in sports and musculoskeletal suggest that two to four months is the brace should be made on an individual medicine: the diagnosis and treatment of average, with less time off required for basis. Many doctors now recommend spondylosis in adolescent athletes. Arch Phys Med Rehabil. 2007;88:537-40. those who participate in low-risk sports using a soft brace with activity to provide (9) 11. Baker RJ., Patel DP. Lower Back Pain in the . The goals of rehab during this time feedback on back position and limit Athlete: Common Conditions and Treatment. is addressing risk factors and increasing extension, while not overly restricting Prim Care Clin Office Pract. 32(2005) 201-229. core strength and low-intensity aerobic motion (4-8). 12. Cavalier R., Herman MJ., et. al. Spondylolysis and Spondylolisthesis in Children and activity without pain. If that works, Adolescents: I. Diagnosis, Natural History the patient may slowly transition to REFERENCES and Nonsurgical Management. J. Am. Acad. 1. Bono CM. Current concepts review: low back Orthop. Surg. 2006;14:417-424. performing sport-specific drills that are pain in athletes. J Bone Joint Surg 2004; 86- low risk (8-9). The athlete should be able A(2):382-96. Knee Osteochondritis Dissecans By Rathna Nuti, MD When a crack forms in the articular locate it in patients where x-rays were avoided if non-operative treatment cartilage in your joints and underlying otherwise normal. MRIs provide more is a viable option, but if the lesion is bone, that is a condition called detailed information that will help with unstable, surgery should be considered. osteochondritis dissecans (OCD) lesions. treatment. This injury typically happens to youth Follow-up: athletes between the ages of 10 to Treatment: • Non-surgical: X-rays are repeated 15 years old, though it can happen in Treatment of OCD lesions depends on every three months to determine if adults, as well. Despite a lot of research, the how bad the injury is and where it’s the lesion is healed. Once healing is the cause of OCD lesions is unclear, but located. If left untreated, it can lead to confirmed, the athlete can gradually genetics, trauma and blood supply to early arthritis in the knee. return to activities under the the injured area are likely factors. The Non-surgical treatment consists of guidance of a physical therapist and/ knee is the most common joint affected modifying activities and restricting or athletic trainer. in the body. Younger individuals prior placing weight on the knee with • Surgical: Post-operative to their growth plates closing have the crutches to protect the injury and management typically consists of best prognosis. This article summarizes allow healing. Ice, anti-inflammatory utilizing analgesics (usually a mix the symptoms, diagnostic work-up and medications and bracing for pain can of opioids and NSAIDs) to control treatment of OCD lesions. also be used. Limiting weight placed on pain, inflammation and swelling the knee should last at least 4-6 weeks as well as immobilization for 4-6 Symptoms: and be closely monitored. Severe cases weeks, depending on the procedure. The most common complaint is knee that are slow to heal can take six months After the period of immobilization, pain that occurs with activity. In addition, to recover. Non-surgical treatment is they should go through physical for OCD lesions can involve separation of the considered in children who have stable therapy 6-8 weeks to regain range articular cartilage from the underlying lesions and open growth plates. The of motion, stretching, progressive bone, causing loose fragments within same goes for adults who have no strengthening and functional or the joint. These can cause a sensation symptoms. Surgery can typically be sport-specific training. of locking or catching in the knee joint. Other symptoms may include stiffness, popping, clicking and/or buckling. Swelling typically occurs, which causes decreased range of motion.

Diagnosis/Imaging: Medical imaging is highly recommended to figure out the diagnosis if an OCD lesion is suspected because early treatment can drastically improve the results. X-rays will likely be performed and can show the OCD lesion and loose fragment, if they’re present. However, x-rays can appear completely normal even if you have the condition. Being able to see it on an x-ray depends on the size of the lesion, its location and the amount of knee bending used while getting the images. The next step is to get an MRI study to look at the lesion for stability or to help

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