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
Jonathan M. Fallon, D.O., M.S. Shoulder Surgery and Operative Sports Medicine www.hamportho.com
– Bone – Soft tissue – Intra-articular pathology
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
Duration Location Type Better/Worse Severity
1. Inguinal Region
Compartment
3. Mid-line/abdominal Structures
3 1 2
Gait Abdominal Exam Spine Exam Knee Exam Limb Lengths
– Psoas, troch, pub sym, adductor
1. Inguinal Pain – Intra-articular
3. Mid-Line Structures
3 1 2
Viscera Bony Architecture Muscle layers dDx:
Athletic Pubalgia Osteitis Pubis Stress fracture Tendonitis
3
3
Disabling lower abdominal/inguinal pain at extremes
Pain at rectus insertion, progresses despite treatment Pain abates with cessation of activity Hyperextension injury with a hyper-abduction of the
Male predominant injury
Chronic inguinal or
Noted on exertion only Not explainable by a
Not explainable by
Kicking and Running
Long Distance Runners
Soccer Players
Weight Lifters
Fencers
Football Players
No Limitation in Hip Motion
Pain Standing Unsupported on Affected Leg (Positive Standing Sign)
Distance runners
Pain with Weight Bearing
Limited Internal Rotation of Hip
Can Be Bilateral (IMAGE BOTH SIDES)
1. Hernia 2. AVN 3. Internal Snapping Hip 4. Intra-articular Snapping Hip
Teres
5. Femoral-Acetabular Impingement
1
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
AVN is the final common pathway
Dislocation Synovial Chondromatosis OCD
Sharp groin pain, Exacerbated with flexion
activities
Catching “C” Sign Radiate to buttock or thigh History of intermittent
groin strain
Limited flexion
and internally rotated
flexed and externally rotated hip
sensitivity)
– Pain when maximally flexed
and internally rotated
– Postero/supero labrum (87%
sensitivity)
– Pain with full extension of a
flexed and externally rotated hip
– Anterior labrum (82%
sensitivity)
– Open dislocation with
– Long term results
show minimal change in outcome
– Minimally invasive – Takedown and repair
possible
Trochanteric Bursitis External Snapping Hip Gluteus Medius
Piriformis Pain
e.g. Contusion or Strain
Trochanteric Bursa
Ischial Bursa
Iliopectineal Bursa
Iliopsoas Bursa
– Friction of IT band over Gr. Troch. – Localized by ER and adduction
– Common in Hockey and Skaters – Exacerbated by Sitting
– Anterior Snapping Hip
– Continuance of Illiopsoas bursa – Irritation of Illiopsoas tendon over
IP eminence
ITB or Gluteus Maximus Sliding Over Trochanter
Inflammation of the Trochanteric Bursa
Iliopsoas Snaps over Iliopectineal Eminence or Femoral Head
Labral Tears, Loose Bodies, Osteochondral Injury
Often History of Trauma
Occur in Active Late Teens and 20’s
Symptoms:
Postero-medial Pain Sitting and transitional
pain
Activity related
Exam
Trendelenburg Sign Isolated Weakness
45’ hip flexion
For recalcitrant Bursitis
Lengthening of IT
band
Debridement or
Repair of Abductors
Violent Eccentric Contraction with Muscle on Stretch
Contused Muscle is Susceptible to Strain Injury
Adductor Longus
Rectus Femoris
External Oblique
Skeletally immature athletes Failure at apophysis
ASIS AIIS Iliac Crest Greater Trochanter Lesser Trochanter Ischial Tuberosity
–
Iliac Crest Most Likely
–
Similar to Other Apophysites
–
Tender to Palpation over Area
Widening if Chronic
Activities Until Discomfort Subsides
Iliac Crest – “Hip Pointer”
Greater Trochanter
Ischial tuberosity
–
Areas of Deep Soft Tissue Injury with Hematoma
–
Around a Joint or Tendon Insertion / Origin
Larson, et al. Evaluating and Managing Muscle Contusions and Myositis Ossificans. Phys Sport Med. Vol 30 / No 2: Feb, 2002.
Piriformis Syndrome
McCrory & Bell. Nerve Entrapment Syndromes as a Cause of Pain in the Hip, Groin and Buttock. Sports Med 1999 Apr; 27 (4): 261- 274.
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
After all else fails… Open vs Arthroscopic
Jonathan M. Fallon, D.O., M.S. www.hamportho.com jfallon@hamportho.com 413-586-8200
Your Office by the Team Trainer After 6 Weeks of Physical Therapy Failed to Improve His Symptoms. X-Rays and MRI
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?
Sports Medicine Self Assessment Examination. American Academy of Orthopaedic Surgery. 2004
Your Office by the Team Trainer After 6 Weeks of Physical Therapy Failed to Improve His Symptoms. X-Rays and MRI
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?
Sports Medicine Self Assessment Examination. American Academy of Orthopaedic Surgery. 2004
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
ultimately manage this condition.
Sports Medicine Self Assessment Examination. American Academy of Orthopaedic Surgery. 2004
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?
Review Questions in Orthpaedics. Wright, et al., Lippincott, Williams and Wilkins. 2002
A 24 Year Old Professional Squash Player Presents with Persistent Right Inguinal Pain and Clicking After an Episode
Respond to a 3 Month Course of Rest, Stretching and
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
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
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
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
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
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:
AOSSM Self Assessment and Board Review. Version 2. American Orthopaedic Society for Sports Medicine. 2006
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:
AOSSM Self Assessment and Board Review. Version 2. American Orthopaedic Society for Sports Medicine. 2006
The most common type of “snapping hip” is external which
Other types of snapping hip include the internal type, which is most commonly seen in ballet dancers. The internal type
pathology including loose bodies and labral tears.
AOSSM Self Assessment and Board Review. Version 2. American Orthopaedic Society for Sports Medicine. 2006