diagnosis and treatment of hip pain in the athlete · avn is the final common pathway . avascular...
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Diagnosis and Treatment of Hip Pain in the Athlete
Jonathan M. Fallon, D.O., M.S. Shoulder Surgery and Operative Sports Medicine
www.hamportho.com
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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 – Soft tissue – Intra-articular pathology
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Differential Diagnosis Orthopaedic Etiology
Adductor strain Rectus femoris strain
Iliopsoas strain Rectus abdominus strain
Muscle contusion Avulsion fracture Gracilis syndrome
Athletic hernia Osteitis pubis
Hip DJD SCFE AVN
Stress fracture Labral tear
Lumbar radiculopathy Ilioinguinal neuropathy Obturator neuropathy
Bony/soft tissue neoplasm Seronegative spondyloarthropathy
Non-Orthopaedic Etiology Inguinal hernia Femoral hernia
Peritoneal hernia Testicular neoplasm
Ureteral colic Prostatitis
Epididymitis Urethritis/UTI
Hydrocele/varicocele Ovarian cyst
PID Endometriosis
Colorectal neoplasm IBD
Diverticulitis
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History Was there an injury? Pain
Duration Location Type Better/Worse Severity
Subjective assessment
Sports
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Location, Location , Location 1. Inguinal Region
2. Peri-Trochanteric
Compartment
3. Mid-line/abdominal Structures
3
1
2
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Physical Examination Gait
Abdominal Exam
Spine Exam
Knee Exam
Limb Lengths
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Physical Examination • Point of maximal tenderness
– Psoas, troch, pub sym, adductor
• C sign
• ROM
• Thomas Test: flexion contracture
• 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.
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Location, Location , Location 1. Inguinal Pain – Intra-articular
-Femoroacetabular Impingment
-Flexor Strain
-Hernia
2. Peri-Trochanteric Compartment
-Trochanteric Bursitis
-Piriformis Syndrome
3. Mid-Line Structures
-Ramus Fx, Osteitis Pubis
-Athletic Pubalgia, Hernia
3
1
2
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Midline Pain - Anatomy Viscera
Bony Architecture
Muscle layers
dDx:
Athletic Pubalgia
Osteitis Pubis
Stress fracture
Tendonitis
3
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Athletic Pubalgia – Gilmore’s groin (Gilmore
1992)
– Sportsman’s hernia (Malycha 1992)
– Incipient hernia
– Hockey Groin Syndrome – Slapshot Gut
– Ashby’s inguinal ligament enthesopathy
3
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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
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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
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Physical Exam Tender to Palpation over
Peripubic Area, Symphysis Pubis, or Adductor Area
No Palpable Hernia
Pain with Resisted Adduction or Situps
Tight Hamstrings or Limited Hip Motion
Neuro Exam Normal
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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
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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)
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Inguinal “Hip” Pain 1. Hernia
2. AVN
3. Internal Snapping Hip
4. Intra-articular Snapping Hip
•Loose Bodies
•Synovial Chondromatosis
•Lesions of the Ligamentum
Teres
•Labral Tear
5. Femoral-Acetabular
Impingement
1
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Inguinal & Femoral Hernias Inguinal Hernia
Persistent Processus Vaginalis
Groin Pain Radiating to Upper Thigh
Worse with Valsalva
Diffrential Diagnosis: Epididymitis
Scrotal Abscess
Testicular Torsion
Varicocele
Spermatocele
Hydrocele
Surgical Repair Endoscopic vs. Open
Femoral Hernia
Under Inguinal Ligament, in Space Medial to the Femoral Vein in the Femoral Triangle
Tender to Palpation and Mass can be Felt
Diagnosis Requires High Index of Suspicion
Open Surgical Repair
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Avascular Necrosis Etiology
Trauma
Sickle Cell
Steroids
Binge Drinking
Idiopathic
AVN is the final common pathway
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Avascular Necrosis Presentation
Insidious Onset
Activity Related
Progressive
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Loose Bodies / Synovial Chondromatosis
Multiple Causes:
Dislocation
Synovial Chondromatosis
OCD
Catching pain
Sharp
Locking
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Femoroacetabular Impingement History
Sharp groin pain,
Exacerbated with flexion activities
Catching
“C” Sign
Radiate to buttock or thigh
History of intermittent groin strain
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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)
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Impingement Mechanism
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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)
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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
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Ruptured Ligamentum Teres History of injury
Pain with flexion and internal rotation
MRI Arthrography may show lesion in fossa
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Tumor Should always be
considered
Night pain, rest pain
Constitutional symptoms
Mets, Primary Tumor, PVNS
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Peritrochanteric/Buttock “Hip Pain”
Trochanteric Bursitis
External Snapping Hip
Gluteus Medius Tendinosis/ Tears
Piriformis Pain
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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
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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
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Snapping Hip Syndrome
Coxa Saltans
External is most common
ITB or Gluteus Maximus Sliding Over Trochanter
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
Occur in Active Late Teens and 20’s
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Gluteus Medius Tear
•Late-Middle age (F>M) •Tendinosis (similar to Rotator Cuff) •Possible cause of recalcitrant Bursitis
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Gluteus Medius Tear Symptoms:
Postero-medial Pain
Sitting and transitional pain
Activity related
Exam
Trendelenburg Sign
Isolated Weakness 45’ hip flexion
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Arthroscopic Bursectomy and Tendon Repair
For recalcitrant Bursitis
Lengthening of IT band
Debridement or Repair of Abductors
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Other “Hip Pain
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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
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Avulsion Fractures Skeletally immature athletes
Failure at apophysis ASIS
AIIS
Iliac Crest
Greater Trochanter
Lesser Trochanter
Ischial Tuberosity
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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
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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
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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
• Treatment is based on clinical findings
Larson, et al. Evaluating and Managing Muscle
Contusions and Myositis Ossificans. Phys Sport Med.
Vol 30 / No 2: Feb, 2002.
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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.
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Treatment Overview Physical Therapy
1st Line Treatment
Range of Motion
US/Deep Tissue release
Graston Technique
Core/Hip Strength
Imaging
Xray
MR Arthrogram
CT (3-D recon)
US – user dependant
Cortisone Injection
Diagnostic and theraputic
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Surgical Treatment After all else fails…
Open vs Arthroscopic
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Thank You - Any Questions?
Jonathan M. Fallon, D.O., M.S. www.hamportho.com
[email protected] 413-586-8200
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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