History the Athlete Was there an injury? Pain Duration Location - PDF document

12/9/2013 Diagnosis and Treatment of Hip Pain in History the Athlete  Was there an injury?  Pain  Duration  Location  Type  Better/Worse  Severity  Subjective Jonathan M. Fallon, D.O., M.S. assessment Shoulder Surgery and Operative Sports Medicine  Sports www.hamportho.com Location, Location , Location Hip and Groin Pain 1. Inguinal Region • Diagnosis difficult and 2. Peri-Trochanteric confusing Compartment • Extensive rehabilitation 3. Mid-line/abdominal Structures • Significant risk for time loss • 5 ‐ 9% of sports injuries 3 • Literature extensive but often contradictory 1 • Consider: 2 – Bone – Soft tissue – Intra ‐ articular pathology Differential Diagnosis Orthopaedic Etiology Non ‐ Orthopaedic Etiology Physical Examination Adductor strain Inguinal hernia Rectus femoris strain Femoral hernia Iliopsoas strain Peritoneal hernia  Gait Rectus abdominus strain Testicular neoplasm Muscle contusion Ureteral colic  Abdominal Exam Avulsion fracture Prostatitis Gracilis syndrome Epididymitis  Spine Exam Athletic hernia Urethritis/UTI Osteitis pubis  Knee Exam Hydrocele/varicocele Hip DJD Ovarian cyst  Limb Lengths SCFE PID AVN Endometriosis Stress fracture Colorectal neoplasm Labral tear IBD Lumbar radiculopathy Diverticulitis Ilioinguinal neuropathy Obturator neuropathy Bony/soft tissue neoplasm Seronegative spondyloarthropathy 1

12/9/2013 Physical Examination Athletic Pubalgia • Point of maximal tenderness – Psoas, troch, pub sym, adductor – Gilmore’s groin (Gilmore • C sign 1992) • ROM – Sportsman’s hernia • Thomas Test: flexion contracture • McCarthy Test: labral pathology (Malycha 1992) • Impingement Test – Incipient hernia 3 • Clicking: psoas vs labrum – Hockey Groin Syndrome – • Resisted SLR: intra ‐ articular • Ober: IT band Slapshot Gut • FABER: SI joint – Ashby’s inguinal ligament • Heel Strike: Femoral neck enthesopathy • Log Roll: intra ‐ articular • Single leg stance – Trendel. Location, Location , Location Athletic Pubalgia - Natural History 1. Inguinal Pain – Intra-articular -Femoroacetabular Impingment  Disabling lower abdominal/inguinal pain at extremes of exertion -Flexor Strain  Pain at rectus insertion, progresses despite treatment -Hernia  Pain abates with cessation of activity 2. Peri-Trochanteric Compartment 3  Hyperextension injury with a hyper ‐ abduction of the -Trochanteric Bursitis thigh 1  Male predominant injury -Piriformis Syndrome 2 3. Mid-Line Structures -Ramus Fx, Osteitis Pubis -Athletic Pubalgia, Hernia Athletic Pubalgia Midline Pain ‐ Anatomy  Meyers et al AJOSM  Viscera ‘00  Bony Architecture  Chronic inguinal or  Muscle layers pubic area pain  Noted on exertion only 3  dDx:  Not explainable by a  Athletic Pubalgia palpable hernias  Osteitis Pubis  Not explainable by  Stress fracture other medical diagnosis  Tendonitis 2

12/9/2013 Physical Exam Inguinal “Hip” Pain  Tender to Palpation over Peripubic Area, Symphysis 1. Hernia Pubis, or Adductor Area 2. A VN 3. Internal Snapping Hip  No Palpable Hernia 4. Intra-articular Snapping Hip •Loose Bodies  Pain with Resisted Adduction •Synovial Chondromatosis 1 or Situps •Lesions of the Ligamentum Teres  Tight Hamstrings or Limited •Labral Tear Hip Motion 5. Femoral-Acetabular Impingement  Neuro Exam Normal Inguinal & Femoral Hernias Osteitis Pubis Inguinal Hernia Femoral Hernia  Inflammatory Process of Symphysis  Persistent Processus  Under Inguinal Ligament, in  Microtrauma from Athletic Activity Vaginalis Space Medial to the Femoral  Kicking and Running Vein in the Femoral Triangle  Groin Pain Radiating to  Occurs in: Upper Thigh  Tender to Palpation and   Long Distance Runners Worse with Valsalva Mass can be Felt  Soccer Players  Diffrential Diagnosis: Weight Lifters   Diagnosis Requires High  Epididymitis  Fencers Index of Suspicion  Scrotal Abscess  Football Players  Testicular Torsion  Imbalance Abdominals and Hip Adductors  Open Surgical Repair Varicocele    Spermatocele Pain with passive abduction and resisted  Hydrocele adduction  Surgical Repair  Often Insidious but Can Be Acute  Endoscopic vs. Open Pelvic Stress Fractures  Repetitive Motion such as Avascular Necrosis Running  Pain Subsides with Rest  Etiology  Rami  Trauma  No Limitation in Hip Motion  Sickle Cell  Pain Standing Unsupported on Affected Leg (Positive Standing  Steroids Sign)  Sacrum  Binge Drinking  Distance runners Pain with Weight Bearing   Idiopathic  Femoral Neck  Limited Internal Rotation of Hip  Can Be Bilateral ( IMAGE BOTH  AVN is the final common pathway SIDES ) 3

12/9/2013 FAI Avascular Necrosis  Presentation  Physical exam  Limited flexion  Insidious Onset • Impingement Sign  Activity Related Pain when maximally flexed • and internally rotated  Progressive • 87% sensitivity • McCarthy’s Sign • Pain with full extension of a flexed and externally rotated hip • Anterior labrum (82% sensitivity) Loose Bodies / Synovial Chondromatosis Impingement Mechanism  Multiple Causes:  Dislocation  Synovial Chondromatosis  OCD  Catching pain  Sharp  Locking Labral Tear Femoroacetabular Impingement • Pain with repetitive twisting  History and strenuous pivoting • Impingement Sign  Sharp groin pain, – Pain when maximally flexed  Exacerbated with flexion and internally rotated activities – Postero/supero labrum (87%  Catching sensitivity)  “C” Sign • McCarthy’s Sign  Radiate to buttock or thigh – Pain with full extension of a flexed and externally rotated  History of intermittent hip groin strain – Anterior labrum (82% sensitivity) 4

12/9/2013 Peritrochanteric/Buttock “Hip Open vs. Arthroscopic Treatment Pain” • Burnese experience  Trochanteric Bursitis – Open dislocation with  External Snapping Hip osteoplasty  Gluteus Medius – Long term results Tendinosis/ Tears show minimal change in outcome  Piriformis Pain • Arthroscopic – Minimally invasive – Takedown and repair possible Ruptured Ligamentum Teres Bursitis  Occurs from Repetitive Friction with  History of injury Nearby Muscle or Traumatic Injury to Surrounding Tissue  Pain with flexion and internal rotation  Can Be Difficult to Differentiate from  MRI Arthrography other Soft Tissue Processes may show lesion in  e.g. Contusion or Strain fossa  Several (13) Bursa About Hip  Four Major Bursa Trochanteric Bursa  Ischial Bursa  Iliopectineal Bursa  Iliopsoas Bursa  Pelvic/Hip Bursitis Tumor • Trochanteric  Should always be – Friction of IT band over Gr. Troch. considered – Localized by ER and adduction  Night pain, rest pain • Ischial – Common in Hockey and Skaters  Constitutional – Exacerbated by Sitting symptoms • Illiopsoas  Mets, Primary Tumor, – Anterior Snapping Hip PVNS • Illiopectineal – Continuance of Illiopsoas bursa – Irritation of Illiopsoas tendon over IP eminence 5

12/9/2013 Snapping Hip Syndrome Arthroscopic Bursectomy and Coxa Saltans Tendon Repair  External is most common  ITB or Gluteus Maximus Sliding Over  For recalcitrant Bursitis Occur in Active Late Trochanter Teens and 20’s  Lengthening of IT  Inflammation of the Trochanteric band Bursa  Debridement or  Internal Repair of Abductors  Iliopsoas Snaps over Iliopectineal Eminence or Femoral Head  Intra ‐ articular Labral Tears, Loose Bodies,  Osteochondral Injury Often History of Trauma  Other “Hip Pain Gluteus Medius Tear • Late ‐ Middle age (F>M) • Tendinosis (similar to Rotator Cuff) • Possible cause of recalcitrant Bursitis Muscle Strains and Tendonitis Gluteus Medius Tear  Cause  Symptoms:  Violent Eccentric Contraction with Muscle on Stretch  Postero ‐ medial Pain  Contused Muscle is Susceptible  Sitting and transitional to Strain Injury pain  May also develop from  Activity related Microtrauma  Exam  Muscles that Cross 2 Joints  Trendelenburg Sign are More Susceptible to  Isolated Weakness Strain  45’ hip flexion Adductor Longus  Rectus Femoris   External Oblique 6