Diagnosis and Treatment of in the Athlete

Jonathan M. Fallon, D.O., M.S. Shoulder Surgery and Operative Sports Medicine www.hamportho.com

Hip and Groin Pain

• Diagnosis difficult and confusing • Extensive rehabilitation • Significant risk for time loss • 5-9% of sports injuries • Literature extensive but often contradictory • Consider: – Bone – – Intra-articular pathology Differential Diagnosis Orthopaedic Etiology Non-Orthopaedic Etiology Adductor strain Inguinal hernia Rectus femoris strain Femoral hernia strain Peritoneal hernia Rectus abdominus strain Testicular neoplasm Muscle contusion Ureteral colic Avulsion fracture Prostatitis Gracilis syndrome Epididymitis Athletic hernia Urethritis/UTI Osteitis pubis Hydrocele/varicocele Hip DJD Ovarian cyst SCFE PID AVN Endometriosis Stress fracture Colorectal neoplasm Labral tear IBD Lumbar radiculopathy Diverticulitis Ilioinguinal neuropathy Obturator neuropathy Bony/soft tissue neoplasm Seronegative spondyloarthropathy History  Was there an injury?  Pain  Duration  Location  Type  Better/Worse  Severity  Subjective assessment  Sports Location, Location , Location 1. Inguinal Region 2. Peri-Trochanteric Compartment 3. Mid-line/abdominal Structures

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1 2 Physical Examination  Gait  Abdominal Exam  Spine Exam  Knee Exam  Limb Lengths Physical Examination • Point of maximal tenderness – Psoas, troch, pub sym, adductor • C sign • ROM • Thomas Test: flexion • McCarthy Test: labral pathology • Impingement Test • Clicking: psoas vs labrum • Resisted SLR: intra-articular • Ober: IT band • FABER: SI joint • Heel Strike: Femoral neck • Log Roll: intra-articular • Single leg stance – Trendel. Location, Location , Location 1. Inguinal Pain – Intra-articular -Femoroacetabular Impingment -Flexor Strain -Hernia 2. Peri-Trochanteric Compartment 3 -Trochanteric 1 -Piriformis Syndrome 2 3. Mid-Line Structures -Ramus Fx, Osteitis Pubis -Athletic Pubalgia, Hernia Midline Pain - Anatomy  Viscera  Bony Architecture  Muscle layers

 dDx: 3  Athletic Pubalgia  Osteitis Pubis  Stress fracture  Tendonitis Athletic Pubalgia – Gilmore’s groin (Gilmore 1992) – Sportsman’s hernia (Malycha 1992) – Incipient hernia 3 – Hockey Groin Syndrome – Slapshot Gut – Ashby’s inguinal ligament

Athletic Pubalgia - Natural History

 Disabling lower abdominal/inguinal pain at extremes of exertion  Pain at rectus insertion, progresses despite treatment  Pain abates with cessation of activity  Hyperextension injury with a hyper-abduction of the thigh  Male predominant injury

Athletic Pubalgia  Meyers et al AJOSM ‘00  Chronic inguinal or pubic area pain  Noted on exertion only  Not explainable by a palpable hernias  Not explainable by other medical diagnosis Physical Exam  Tender to Palpation over Peripubic Area, Symphysis Pubis, or Adductor Area

 No Palpable Hernia

 Pain with Resisted Adduction or Situps

 Tight or Limited Hip Motion

 Neuro Exam Normal Osteitis Pubis  Inflammatory Process of Symphysis  Microtrauma from Athletic Activity  Kicking and Running  Occurs in:  Long Distance Runners  Soccer Players  Weight Lifters  Fencers  Football Players  Imbalance Abdominals and Hip Adductors  Pain with passive abduction and resisted adduction  Often Insidious but Can Be Acute Pelvic Stress Fractures  Repetitive Motion such as Running  Pain Subsides with Rest

 Rami  No Limitation in Hip Motion  Pain Standing Unsupported on Affected Leg (Positive Standing Sign)  Sacrum  Distance runners  Pain with Weight Bearing  Femoral Neck  Limited Internal Rotation of Hip  Can Be Bilateral (IMAGE BOTH SIDES) Inguinal “Hip” Pain

1. Hernia 2. AVN 3. Internal Snapping Hip 4. Intra-articular Snapping Hip •Loose Bodies •Synovial Chondromatosis 1 •Lesions of the Ligamentum Teres •Labral Tear 5. Femoral-Acetabular Impingement Inguinal & Femoral Hernias Inguinal Hernia Femoral Hernia  Persistent Processus  Under Inguinal Ligament, in Vaginalis Space Medial to the Femoral  Groin Pain Radiating to Vein in the Femoral Triangle Upper Thigh  Worse with Valsalva  Tender to Palpation and Mass can be Felt  Diffrential Diagnosis:  Epididymitis  Diagnosis Requires High  Scrotal Abscess Index of Suspicion  Testicular Torsion  Varicocele  Open Surgical Repair  Spermatocele  Hydrocele  Surgical Repair  Endoscopic vs. Open Avascular Necrosis Etiology  Trauma  Sickle Cell  Steroids  Binge Drinking  Idiopathic

 AVN is the final common pathway Avascular Necrosis Presentation  Insidious Onset  Activity Related  Progressive Loose Bodies / Synovial Chondromatosis  Multiple Causes:  Dislocation  Synovial Chondromatosis  OCD  Catching pain  Sharp  Locking

Femoroacetabular Impingement  History  Sharp groin pain,  Exacerbated with flexion activities  Catching  “C” Sign  Radiate to buttock or thigh  History of intermittent groin strain

FAI  Physical exam  Limited flexion • Impingement Sign • Pain when maximally flexed and internally rotated • 87% sensitivity • McCarthy’s Sign • Pain with full extension of a flexed and externally rotated hip • Anterior labrum (82% sensitivity)

Impingement Mechanism Labral Tear • Pain with repetitive twisting and strenuous pivoting • Impingement Sign – Pain when maximally flexed and internally rotated – Postero/supero labrum (87% sensitivity) • McCarthy’s Sign – Pain with full extension of a flexed and externally rotated hip – Anterior labrum (82% sensitivity) Open vs. Arthroscopic Treatment

• Burnese experience – Open dislocation with osteoplasty – Long term results show minimal change in outcome • Arthroscopic – Minimally invasive – Takedown and repair possible Ruptured Ligamentum Teres  History of injury  Pain with flexion and internal rotation  MRI Arthrography may show lesion in fossa Tumor  Should always be considered  Night pain, rest pain  Constitutional symptoms  Mets, Primary Tumor, PVNS Peritrochanteric/Buttock “Hip Pain”

 Trochanteric Bursitis  External Snapping Hip  Tendinosis/ Tears  Piriformis Pain

Bursitis  Occurs from Repetitive Friction with Nearby Muscle or Traumatic Injury to Surrounding Tissue

 Can Be Difficult to Differentiate from other Soft Tissue Processes  e.g. Contusion or Strain

 Several (13) Bursa About Hip

 Four Major Bursa  Trochanteric Bursa  Ischial Bursa  Iliopectineal Bursa  Iliopsoas Bursa Pelvic/Hip Bursitis • Trochanteric – Friction of IT band over Gr. Troch. – Localized by ER and adduction • Ischial – Common in Hockey and Skaters – Exacerbated by Sitting • Illiopsoas – Anterior Snapping Hip • Illiopectineal – Continuance of Illiopsoas bursa – Irritation of Illiopsoas tendon over IP eminence

Snapping Hip Syndrome Coxa Saltans

 External is most common  ITB or Sliding Over Occur in Active Late Trochanter Teens and 20’s  Inflammation of the Trochanteric Bursa  Internal  Iliopsoas Snaps over Iliopectineal Eminence or Femoral Head  Intra-articular  Labral Tears, Loose Bodies, Osteochondral Injury  Often History of Trauma Gluteus Medius Tear

•Late-Middle age (F>M) •Tendinosis (similar to Rotator Cuff) •Possible cause of recalcitrant Bursitis Gluteus Medius Tear  Symptoms:  Postero-medial Pain  Sitting and transitional pain  Activity related  Exam  Trendelenburg Sign  Isolated Weakness  45’ hip flexion

Arthroscopic Bursectomy and Tendon Repair

 For recalcitrant Bursitis  Lengthening of IT band  Debridement or Repair of Abductors Other “Hip Pain Muscle Strains and Tendonitis

 Cause  Violent Eccentric Contraction with Muscle on Stretch  Contused Muscle is Susceptible to Strain Injury  May also develop from Microtrauma

 Muscles that Cross 2 Joints are More Susceptible to Strain  Adductor Longus  Rectus Femoris  External Oblique

Avulsion Fractures  Skeletally immature athletes  Failure at apophysis  ASIS  AIIS  Iliac Crest  Greater Trochanter  Lesser Trochanter  Ischial Tuberosity Apophysitis • Can Occur Anywhere in Hip Girdle – Iliac Crest Most Likely

• Overuse phenomenon – Similar to Other Apophysites

• Diagnosis by Clinical Exam – Tender to Palpation over Area

• Radiographs Show Physeal Widening if Chronic

• Treat by Modifying Offending Activities Until Discomfort Subsides Contusions  Most Common Athletic Hip Injury

 Usually Collision with Another Player, Equipment Collision or Fall to Surface

 Can Occur Over Bony Prominences:  Iliac Crest – “Hip Pointer”  Greater Trochanter  Ischial tuberosity

Myositis Ossificans • Occurs In: – Areas of Deep Soft Tissue Injury with Hematoma – Around a Joint or Tendon Insertion / Origin

• Presents as Painful Mass Associated with Loss of Motion

• Radiographs Lag Behind

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. Nerve Entrapment Syndromes  Sciatic  Piriformis Syndrome  Obturator  Pudendal  Ilioinguinal  Femoral  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- 274.

Treatment Overview

 Physical Therapy  Imaging  1st Line Treatment  Xray  Range of Motion  MR Arthrogram  US/Deep Tissue  CT (3-D recon) release  US – user dependant  Graston Technique  Cortisone Injection  Core/Hip Strength  Diagnostic and theraputic

Surgical Treatment

 After all else fails…  Open vs Arthroscopic Thank You - Any Questions?

Jonathan M. Fallon, D.O., M.S. www.hamportho.com [email protected] 413-586-8200 Questions • A 25 Year Old Professional Hockey Player is Referred to Your Office by the Team Trainer After 6 Weeks of Physical Therapy Failed to Improve His Symptoms. X-Rays and MRI 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 General 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 Questions • A 25 Year Old Professional Hockey Player is Referred to Your Office by the Team Trainer After 6 Weeks of Physical Therapy Failed to Improve His Symptoms. X-Rays and MRI 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 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.

Sports Medicine Self Assessment Examination. American Academy of Orthopaedic Surgery. 2004 Questions

• A 24 Year Old Professional Squash Player Presents with Persistent Right Inguinal Pain and Clicking After an Episode of Lunging for a Backhand. A Plain Radiograph is Unremarkable. MR Arthrogram reveals a Labral Tear. He Has Failed to Respond to a 3 Month Course of Rest, Stretching and NSAIDs. Which is the Most Appropriate Treatment Plan?

• A) Hip Arthroscopy and Debridement • B) Arthrotomy and Repair • C) Right Inguinal Herniorrhaphy • D) Electromyography • E) CT Guided Needle Biopsy Review Questions in Orthpaedics. Wright, et al., Lippincott, Williams and Wilkins. 2002 Questions  A 24 Year Old Professional Squash Player Presents with 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 Respond to a 3 Month Course of Rest, Stretching and NSAIDs. Which is the Most Appropriate Treatment Plan?

 A) Hip Arthroscopy and Debridement  B) Arthrotomy and Repair  C) Right Inguinal Herniorrhaphy  D) Electromyography  E) CT Guided Needle Biopsy Review Questions in Orthpaedics. Wright, et al., Lippincott, Williams and Wilkins. 2002 Questions  A) Hip Arthroscopy and Debridement

 Labral tears typically affect the anterosuperior portion of the acetabulum rim. They are more common in the presence of acetabular dysplasia. After lack of response to an adequate course of conservative management, arthroscopic evaluation and debridement of the involved portion of the labrum are appropriate.

Review Questions in Orthpaedics. Wright, et al., Lippincott, Williams and Wilkins. 2002 Questions  Which of the Following Best Describes Athletic Pubalgia?

 A) A Syndrome of Lower Abdominal and Adductor Pain  B) Painful Symptoms Emanating from the Symphysis Pubis  C) Painful Symptoms Associated with Dysfunction of the Iliopsoas Tendon  D) Stress Fracture of the Pubic Ramus  E) Entrapment of the Pudental Nerve

Sports Medicine Self Assessment Examination. American Academy of Orthopaedic Surgery. 2004 Questions  Which of the Following Best Describes Athletic Pubalgia?

 A) A Syndrome of Lower Abdominal and Adductor Pain  B) Painful Symptoms Emanating from the Symphysis Pubis  C) Painful Symptoms Associated with Dysfunction of the Iliopsoas Tendon  D) Stress Fracture of the Pubic Ramus  E) Entrapment of the Pudental Nerve

Sports Medicine Self Assessment Examination. American Academy of Orthopaedic Surgery. 2004 Questions  A) A Syndrome of Lower Abdominal and Adductor Pain

 Athletic pubalgia is a distinct syndrome of lower abdominal and adductor pain that is most commonly seen in high performance male athletes. This condition must be distinguished from others such as painful inflammation of the symphasis pubis, referred to as osteitis pubis and “snapping hip” symptoms attributable to the iliopsoas tendon.

Sports Medicine Self Assessment Examination. American Academy of Orthopaedic Surgery. 2004 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  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