Diagnosis and Treatment of Hip Pain in the Athlete Jonathan M. - PowerPoint PPT Presentation

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

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

Differential Diagnosis Orthopaedic Etiology Non-Orthopaedic Etiology Adductor strain Inguinal hernia Rectus femoris strain Femoral hernia Iliopsoas 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 3 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 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.

Location, Location , Location Inguinal Pain – Intra-articular 1. -Femoroacetabular Impingment -Flexor Strain -Hernia 2. Peri-Trochanteric Compartment 3 -Trochanteric Bursitis 1 -Piriformis Syndrome 2 3. Mid-Line Structures -Ramus Fx, Osteitis Pubis -Athletic Pubalgia, Hernia

Midline Pain - Anatomy  Viscera  Bony Architecture  Muscle layers 3  dDx:  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 enthesopathy

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 Hamstrings 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. A VN 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   Under Inguinal Ligament, in Persistent Processus Vaginalis Space Medial to the Femoral Vein in the Femoral Triangle  Groin Pain Radiating to Upper Thigh  Tender to Palpation and  Worse with Valsalva Mass can be Felt  Diffrential Diagnosis:  Diagnosis Requires High Epididymitis  Index of Suspicion  Scrotal Abscess Testicular Torsion   Open Surgical Repair Varicocele   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  Gluteus Medius 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 Gluteus Maximus Sliding Over  Occur in Active Late Teens and 20’s 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 

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 