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

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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

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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

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 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

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

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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.

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

Midline Pain ‐ Anatomy

 Viscera  Bony Architecture  Muscle layers  dDx:

 Athletic Pubalgia  Osteitis Pubis  Stress fracture  Tendonitis

3

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

Athletic Pubalgia - Natural History

 Disabling lower abdominal/inguinal pain at extremes

  • f 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

  • ther 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

  • r 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. 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

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

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

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)

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Open vs. Arthroscopic Treatment

  • Burnese experience

– Open dislocation with

  • steoplasty

– 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

  • ther 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

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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

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

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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

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.

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.

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

Thank You ‐ Any Questions?

Jonathan M. Fallon, D.O., M.S. www.hamportho.com jfallon@hamportho.com 413‐586‐8200

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

  • f 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

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

  • f 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

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

  • rthopaedist, but a general surgeon is best suited to

ultimately manage this condition.

Sports Medicine Self Assessment Examination. American Academy of Orthopaedic Surgery. 2004

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

  • f 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

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

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

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

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

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

Questions

  • B. Between the IT band and the greater trochanter

 The most common type of “snapping hip” is external which

  • ccurs 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

  • ccurs 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