hip and pelvis injuries · anatomy & biomechanics • analysis of emg activity shows • that...
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Hip & Pelvis InjuriesVasileios Sakellariou
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Introduction
• Athletic injuries about the hip and groin
• low frequency relative to injuries at the more distal lower extremities.
• approximately 5% to 9% of the injuries in high school athletes
• rehabilitation times can be prolonged
• early and accurate diagnosis essential
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Anatomy & biomechanics• The major ligaments of the
pelvis and hip are known to be the strongest in the body
• The acetabular labrum deepens the acetabulum and increases articular congruence.
• The anterior iliofemoral ligament (inverted Y-ligament of Bigelow) extends from the anterior inferior iliac spine to the intertrochanteric line of the femur
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Anatomy & biomechanics
• The ischiofemoral ligament, which originates posteriorly along the ischium and travels anteriorly to the neck of the femur, is tightened by flexion
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Anatomy & biomechanics• muscles about the hip joint are
generally at a mechanical disadvantage because of a relatively
• short lever arm and
• must produce forces across the joint that are several times body weight.
• level walking can produce forces of up to 6 times body weight
• jogging with a stumble increased these forces to up to 8 times body weight.13
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Anatomy & biomechanics
• normal hip joint is capable of a flexion/extension arc of approxi- mately 140°
• but one study has shown that slow-paced jogging used only about 40° of this arc.63
• This increases somewhat as pace increases.
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Anatomy & biomechanics
• Analysis of EMG activity shows
• that the rectus femoral and iliac muscles are very active with swing-phase hip flexion,
• while the hamstring muscles act eccentrically to control hip flexion and decelerate knee extension.57
• when running, the body is propelled forward primarily through hip flexion and knee extension rather than by push-off with ankle plantar flexion.
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Common Hip & Groin Conditions Affecting
Athletes
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Acute onset
Muscle Strains
• the most common injuries about the hip and groin
• resulting from athletic competition are muscle strains.
• these often occur in muscles that cross two joints and during an eccentric contraction (in which external load exceeds muscle force)
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Acute onset
Strain or tear
• occurs at the myotendinous junction,
• also commonly seen in the muscle belly.27, 28, 79
• The same mechanism that results in a muscle strain in an adult may cause an apophyseal avulsion in an adolescent
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Prevention
• topic of interest among athletic trainers and physicians.
• strengthening with consideration of appropriate agonist and antagonist relationships
• stretching• and appropriate warmup are important components of prevention.
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Symptoms
• Groin or medial thigh pain is the most common complaint, particularly
• when the patient is asked to adduct the leg against resistance• Focal tenderness and swelling are detected;
• with more severe injuries, a defect may be palpable.
• Objective weakness may be difficult to ascertain, depending on the muscle involved
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Imaging
• Potential avulsions should be ruled out by analysis with an AP pelvis radiograph.
• MRI may be useful
• Factors associated with longer recovery time.
• greater than 50% cross-sectional area involvement,
• fluid collections,
• and deep muscle tears
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Strains of the rectus femoris muscle
• Palpable swelling and tenderness in the anterior thigh,
• 8 to 10 cm below the anterior superior iliac spine
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Strains of the rectus femoris muscle
• result from an explosive hip flexion maneuver,
• sprinting or kicking, or from
• eccentric overload as the hip is extended.
• painful and possibly weak knee extension or hip flexion.
• may be associated with significant swelling
• potentially a cause of femoral nerve palsy
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Treatment• control of hemorrhage and edema
• compressive wrap, ice, and rest.
• gentle range of motion exercises may be started.
• nonsteroidal antiinflammatory medications.
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Treatment
• Return to full activity
• only when the athlete is pain-free.
• recurrences may be more severe, requiring even longer rehabilitation time
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Hip & Thigh Contusions
• result of a direct blow to the iliac crest,
• point tenderness,
• ecchymosis
• muscle spasm
• Deep bleeding and swelling
• subperiosteal,
• intramuscular, or
• subcutaneous.
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Hip & Thigh Contusions
• The iliac crest has multiple muscle origins and insertions:
• internal and external oblique,
• latissimus dorsi,
• paraspinal muscles,
• fascia gluteus medius muscle
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Hip & Thigh Contusions
• Avulsion of these muscles:
• Resisted contraction of these muscles, if avulsed, may exacerbate symptoms
• hematoma formation
• pressure on adjacent nerves
• femoral or lateral femoral cutaneous nerve (meralgia paraesthetica)
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Proximal Thigh Contusions• result of direct trauma.
• muscle is typically compressed between the external force and the subjacent bone.
• often significant hemorrhage and swelling.
• minimize complications such as
• myositis ossificans or
• loss of motion and
• improve functional outcome
•
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Proximal Thigh Contusions
• The initial treatment
• rest,
• immobilization in knee flexion,
• ice
• compression
• maintain motion
• minimize hematoma formation
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Proximal Thigh Contusions• Weightbearing is limited
• until the patient has good quadriceps muscle control and 90°
• pain-free knee motion
• Functional rehabilitation and nonimpact sports a
• when the arc of motion has reached 120°
• no residual muscle atrophy.
• Return to full activity • normal strength
• full range of motion
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Avulsion & Apophyseal injuries
• Avulsion injuries about the pelvis are more common in skeletally immature patients.
• These occur at essentially every major muscle attachment
• result of a violent muscle contraction
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Avulsion & Apophyseal injuries
• history-taking:• mechanism of injury, usually the key
to the diagnosis.
• maintain a position that reduces tension
• localized tenderness,
• swelling,
• eventual ecchymosis
• resisted contraction or stretch reproduces the pain.
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Avulsion & Apophyseal injuries
• anterior superior iliac spine >>> sartorius muscle,
• anterior inferior iliac spine >>> direct head of the rectus femoris muscle
• lesser trochanter >>> iliopsoas tendon during hip flexion
• history of trauma,
• a neoplasm must be suspected.1,42
• surgical fixation
• if the fragment is of sufficient size
• displacement is 2 cm or greater.
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Avulsion & Apophyseal injuries
initial treatment • protected weightbearing
• light stretching
• weightbearing
• after full, pain-free range of motion is achieved,
• strengthening can begin.
• return to competition
• until full strength and motion are restored
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Ischial tuberosity fractures “hurdler’s fractures”
• result of hip flexion with knee extension,
• causing excessive hamstring muscle tension.
• also frequently occur during water skiing.68
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Ischial tuberosity fractures “hurdler’s fractures”
• history of acute trauma
• cause prolonged pain
• referred pain to the posterior parts of the thigh
• late sciatic nerve palsy that responded to mass excision and neurolysis
• changes in seated weightbearing distribution
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Hip dislocation - Subluxation
• uncommon in athletics
• subluxation may be more frequent
• but is poorly recognized.
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Hip dislocation - Subluxation
• In primary dislocations,
• posterior direction are significantly more common.
• anterior dislocations account for only 8% to 15% of the total number.71
• secondary to a collision in skiing and contact sports.
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Hip dislocation - Subluxation
Presentation
• posterior: with the leg flexed, adducted, and internally rotated;
• anterior: with the leg in external rotation, abduction, and either extension or flexion.
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Hip dislocation - Subluxation
• This injury is a surgical emergency
• requiring immediate neurovascular examination
• followed by reduction
• and follow-up examinations.
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Hip dislocation - Subluxation
• Dislocations are usually well demonstrated on an initial AP pelvis radiograph.
• After reduction, a CT or MRI scan is recommended to assure a concentric reduction without loose fragments in the joint.
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Treatment
• Without associated fractures:
• with crutches and partial weightbearing for 6 to 8 weeks
• with gradual range of motion and strengthening afterward.
• The most common complication is osteonecrosis, which occurs in 10% to 20% of patients,
• depending on the patient’s age, severity of injury
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Labral tears
• sharp pain with
• passive flexion,
• internal rotation
• posterior load.
• Arthrography has been shown to identify 88% of labral tears while concurrently enabling injection of local anesthetic.22
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Labral tears• The role of MRI has been
expanding
• rule out other articular lesions,
• loose bodies
• avascular necrosis.
• intra-articular gadolinium to obtain an MRI arthrogram;
• reported sensitivity of 90%
• accuracy of 91%.14
•
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Treatment• partial weightbearing for 4 weeks. • local anesthetic injection may be both
diagnostic and therapeutic.10
• arthroscopic repair
• promising in patients without osteoarthritis or dysplasia.
• 71% of patients had good results after a mean of 34 months.21
•
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Treatment
• arthroscopic complications
• neurovascular structures.
• transient and have eventually resolved.25
• due to the traction necessary for arthroscopic visualization
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Hip fractures
• cross-country and alpine skiing;
• termed “skier’s hip.”
• Displaced, intracapsular fractures are a surgical emergency requiring rapid reduction and internal fixation
• risk of osteonecrosis.
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Hip fractures
• Radiographs are usually adequate for diagnosis.
• Sports-related injuries in adults are treated the same way.
• Children and adolescents should be treated with appropriately sized instrumentation with efforts to protect the growth plate.
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Groin pain & Hernias• accounts for only 5% of patient visits to
clinics,
• much larger proportion of time lost from competition.29, 66
• The “sports hernia” or “hockey hernia” • sports that require repetitive twisting
and turning at speed
• ice hockey, soccer, tennis, and field hockey.
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Etiology• Athletic pubalgia may be a more
appropriate term
• an overuse syndrome.
• Hip abduction, adduction, and flexion-extension
• pull from the adductor musculature against a fixed lower extremity
• attenuation or tearing of the transversalis fascia or conjoined tendon has been suggested as the source of pain
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Etiology• abnormalities at the insertion of the rectus
abdominis muscle53,7
• avulsions of part of the internal oblique muscle fibers at the pubic tubercle.78
• external oblique muscle and aponeurosis.
• entrapment of the genital branches of the
• ilioinguinal n.
• genitofemoral n.
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Etiology
• sudden tearing sensation.
• coughing and sneez- ing
• imbalance exists between
• the strong adductor muscles and
• the relatively weak lower abdomen.
• attenuation, avulsion, or tearing of structures in the pelvic floor
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Imaging• Plain radiographs and a bone scan
• to exclude coexisting abnormalities
• osteitis pubis,
• adductor tenoperiosteal lesions,
• symphyseal instability,
• osteoarthritis,
• tumor.
• MRI image
• abnormalities within the muscles
• or pubic symphysis.19
• Ultrasonography would theoretically be well suited for diagnosis
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Treatment• Nonoperative treatment
• Surgery if nonoperative fails after 6 to 8 weeks,
• high-level athlete.53
• Herniorrhaphy
• conventional
• laparoscopic approach.4, 37, 78
• reinforced with mesh
• return to sports within 6 to 12 weeks after
• specific rehabilitation targeted
• abdominal strengthening,
• adductor muscle flexibility,
• graduated return to activity.41, 78
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Osteitis pubis• result of repetitive trauma
• runners,
• soccer players,
• swimmers,
• hockey players.
• Tension from the adductor muscles or rectus abdominus muscles has been implicated.
• component of or overlap with the sports hernia.
• pain with kicking, running, jumping, or twisting.
• Clicking may indicate instability
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Imaging• Radiographs
• resorption or sclerosis of bone adjacent to the pubic symphysis
• instability or symphysis step-off or even sacroiliac joint changes may be seen.
• Scintigraphy is also diagnostic.
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Treatment• rest and nonsteroidal antiinflammatory medications.
• moist heat may relieve pain and spasm.
• If the athlete does not progress with these measures,
• corticosteroid injection.35
• Once the patient is pain-free,
• stretching and hip range of motion exercises may be started.
• The course may be protracted over 3 months and there is occasional recurrence.
• Adductor tenotomy has also been used for treat- ment of this condition with moderate success.2
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Bursitis• most commonly occurs at the
greater trochanter • an “internal” variety can occur at
the iliopsoas tendon.
• women with a wide pelvis or prominent trochanter
• or runners who adduct beyond midline be at risk.
• Patients have focal tenderness or warmth
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Treatment• Rest, stretching of the involved tendons,
• non-steroidal antiinflammatory medications
• Occasional steroid injection may be useful.
• The injection of a local anesthetic can also be diagnostic.
• Refractory cases
• excision of the bursa or
• lengthening of the involved tendons
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Snapping Hip Syndrome
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Snapping Hip Syndrome• Rest, stretching of the involved tendons,
• non-steroidal anti-inflammatory medications
• Occasional steroid injection may be useful.
• The injection of a local anesthetic can also be diagnostic.
• Refractory cases
• excision of the bursa or
• lengthening of the involved tendons
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Treatment• For refractory cases, multiple surgical procedures such as
• excision of all or part of the iliotibial band,
• Z-plasty, or
• fixation of the iliotibial band to the greater trochanter
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Internal variety The internal variety of bursitis
• by the iliopsoas tendon catching on
• the pelvic brim (iliopectineal eminence)
• or the femoral head.
• hip is extended and the tendon travels from a relative anterolateral position to a more posteromedial position.
• chronic bursitis
• treated similarly, primarily with
• activity modification
• and stretching.
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Internal variety
• Ultrasonography during hip motion
• demonstrates the tendon subluxation.38
• Bursography can also demonstrate this phenomenon
• rarely necessary.
• Again, persistent cases may be treated with
• surgical tendon lengthening.
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Stress Fractures• Endurance athletes or military recruits
• women athletes, especially runners.
• Athletes triad with eating disorders and irregular menses.
• hip region (1.25% to 18%).45,50
• potential consequences of missed or delayed diagnosis.40
• training errors
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Stress Fractures• Increases in training distance
• should not exceed 10% per week.
• pain
• with axial loading or
• with standing or
• hopping on the involved leg.
• insidious onset of pain to the point of inability to run.
• Initial symptoms
• anterior thigh pain that increases with activity
• in an endurance athlete.5
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Imaging• Imaging usually involves scintography or MRI, • radiographs are often negative;
• CT may demonstrate sclerosis and subtle displacement.
• Femoral neck stress fractures are often classified as
• tension side (superior) versus
• compression side (inferior),
• tension fractures are unstable and have a poor prognosis.24
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Treatment
• Rest for stable, compression-side fractures
• Nonimpact activities
• become pain-free.
• Jogging avoided for 4 to 6 weeks • close observation is mandatory
• displacement can lead to disastrous consequences
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Complications
• complication rate of up to 50%.
• osteonecrosis,
• re-fractures,
• pseudarthroses.40
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Osteoarthritis
• seemingly age-old debate
• as to whether sports participation
• predisposes to osteoarthritis
• or actually protects against it
• regular, moderate activity is beneficial,
• excessive loading, underlying injury or abnormality, accelerates the degenerative process
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Osteoarthritis• Repetitive microtrauma to the articular
cartilage and subchondral bone
• Elite athletes more radiographic changes of OA
• Underwent total hip arthroplasty,
• high exposure to sports,
• when combined with jobs that require much physical endurance,
• greatly increased relative risk of osteoarthritis.81
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TreatmentEarly management
• Range of motion exercises
• cyclooxygenase-2 enzyme (COX-2)-specific nonsteroidal antiinflammatory medications
• glucosamine and chondroitin sulfate
• pain relief
• PRP injections
• Stem cells (adipose tissue)
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Treatment
• The role of arthroscopy
• treatment of early osteoarthritis is evolving.
• arthroscopic debridement
• loose body removal
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Other sources of groin & pelvic pain
• Referred pain from
• lower lumbar and
• sacral nerves
• Facet joint and erector spinae muscle abnormalities may also be referred in this distribution.
• The upper lumbar nerves (L1–3) travel anteriorly and may be the source of groin or thigh pain.
• The femoral nerve stretch test causes anterior pain.
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Other sources of groin & pelvic pain
• Cyclists
• pudendal neuropathy
• groin pain and numbness.82
• Activity and equipment modification
• dorsal branch of the pudendal nerve
• between the symphysis pubis and the bicycle seat,
• resulting in a temporary ischemic insult to the nerve.
• The genital branch of the genitofemoral nerve
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Other sources of groin & pelvic pain
• Treatment and prevention
• repositioning the bicycle seat
• does not tilt upward.
• Sometimes the problem can be resolved by
• changing to a different seat,
• modifying the seat,
• or using padded bicycle pants
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Lateral femoral cutaneous nerve compression
• Lateral femoral cutaneous nerve
• compressed by belts, pads, blunt trauma,
• or prolonged hip flexion.
• Pain and paresthesia
• anterolateral thigh with absence of motor findings
• Sensory loss on the anterolateral thigh
• positive Tinel’s sign over the nerve are diagnostic.
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Treatment
• simple removal of the offending compression
• local use of injected antiinflammatory agents
• surgical decompression (rarely necessary)
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Compression of Sciatic Nerve
• Compression of the sciatic nerve occurs near either
• the piriform or
• hamstring muscles
• radiculopathy must be ruled out.
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Compression of Sciatic Nerve
• Patients with piriformis muscle syndrome
• pain with sitting or
• with internal rotation of the hip.
• Patients with hamstring muscle syndrome
• have symptoms in a lower distribution
• mainly with hamstring muscle stretch.
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Slipped Capital Femoral Epiphysis
• Fairly common disorder in adolescence
• precipitated during sports participation.
• African Americans
• obese children
• hormonal imbalances such as hypothyroidism.
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Slipped Capital Femoral Epiphysis
Presentation
• hip or groin pain, or symptoms
• referred to the knee joint.
• internal rotation is limited because the femoral neck is usually externally rotated and is positioned anterior to the femoral head.
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Slipped Capital Femoral Epiphysis
• Radiographs
• graded on percent slippage of the epiphysis
• relative to the superior aspect of the femoral neck
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Slipped Capital Femoral Epiphysis
Treatment
• Most authors now advocate a single anteroposterior percutaneous screw for fixation of acute and chronic slips.
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Summary• Injuries to structures about the hip joint occur despite the fact that
these structures are well adapted to withstand forces of up to several times body weight.
• Information is slowly increasing regarding
• intra-articular hip abnormalities
• many complex soft tissue injuries about the pelvis.
• This increasing body of knowledge spans the expertise of several medical specialties and reinforces the need for a multidisciplinary approach to these athletic injuries.
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Thank you!