Hip Injuries in Athletics PartI

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Sports Injuries of the Hip: Sports Injuries of the Hip Lloyd Barker, PAC, ATC Mayo Clinic Scottsdale Department of Orthopaedic Surgery May 20, 2006

Common Expert Lecture Terminology: Common Expert Lecture Terminology 'It’s my understanding…' (Has never seen one before.) 'Current literature reports…' (Has never seen one, but has read about it once.) 'In my experience…' (Has seen one example.) 'In the series of cases I have managed…' (Has seen two examples!)

Etiology of Hip/Pelvic Pain in the Athlete by system:: Etiology of Hip/Pelvic Pain in the Athlete by system: Gynecological PID, Endometriosis, Pregnancy Psychological: Depression, Anxiety Myofacial: Fibromyalgia Urological: Interstitial cystitis, UTI, Prostatitis Gastrointestinal: Colitis, Diverticulitis, Constipation, IBS Other: Infection, Tumor, Rheumatoid condition Musculoskeletal Today’s topic!

Hip/Pelvic Injuries in the Athlete: Hip/Pelvic Injuries in the Athlete Hips and pelvis critical to performance in sport. Injuries to this region account for 5% of athletic injuries.

Hip/Pelvic Injuries in the Athlete: Hip/Pelvic Injuries in the Athlete Knowledge of the anatomy is critical for the proper diagnosis and treatment of injuries: Bones Sacrum, Rami, Ilium, Ischium, Proximal Femur Joints Hip, Sacroiliac, Pubis Symphis Soft tissues Muscle, Nerve, Tendon, Ligaments, Bursae

Innominate Bone: Innominate Bone Ischium Ilium Pubis Sciatic Notch ASIS

Musculature: Musculature FLEXION Psoas Iliacus Pectineus Rectus Femoris Sartorius Adductors EXTENSION Gluteus maximus Biceps Femoris Semitendinosus Semimembranosus

Musculature: Musculature ABDUCTION Gluteus medius Gluteus minimus Tensor Fascia Latae Sartorious ADDUCTION Adductor longus Adductor brevis Adductor magnus Pectineus Gracilis

Musculature: Musculature LATERAL ROTATION (EXTERNAL) Obturator externus Obturator internus Gemelli Quadratus femoris Sartorius Piriformis MEDIAL ROTATION (INTERNAL) Iliopsoas Gluteal medius (AF) Gluteal minimus (AF) Tensor Fascia Latae

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Hip/Pelvic Injuries in the Athlete: Hip/Pelvic Injuries in the Athlete Thorough history is important part of evaluation. Points to consider: Mechanism of injury, if known. History of previous athletic injuries. Location, quality, severity, duration, timing of pain. Type of sport and position played. Age of athlete.

Hip/Pelvic Injuries in the Athlete: Hip/Pelvic Injuries in the Athlete Important factors to consider (continued): Type of athlete. Level of training. Changes in training habits. Exacerbating or modulating factors. Always keep non-sports conditions in mind, especially tumor and infection.

Range of MotionPhysical Examination of the Spine & Extremities – Stanley Hoppenfeld: Range of Motion Physical Examination of the Spine andamp; Extremities – Stanley Hoppenfeld Flexion – 120o Extension – 30o Abduction – 45o – 50o Adduction – 20o – 30o Internal Rotation – 35o External Rotation – 45o

Slide14: 'Could you listen to me without that bored look?'

Contusion (bruise): Contusion (bruise) Usually caused by direct trauma. Hip pointer - Iliac crest area vulnerable due to lack of soft tissue coverage. Thigh area highly vascular due to large muscle mass. Marked by ecchymosis. Can be painfully debilitating.

Contusion: Contusion

Thigh and Hip Protection: Thigh and Hip Protection

Myositis ossificans: Myositis ossificans Ectopic bone formation within the muscle. Results from a single severe trauma or repetitive blows to same area. Injury Hemorrhage Acute Inflammation Calcification in Muscle Treatment Too aggressive initially, including massage. Avoidance of heat modalities. Blind neglect. May require surgery. High incidence of recurrence if surgery done too early.

Myositis ossificans: Myositis ossificans 24 year old rugby player 5 weeks after injury

Muscle Strain: Muscle Strain Quadriceps v. Hamstrings Hamstrings Decelerators of leg swing. Change in direction or speed. Strength 60 -70% Quads strength. Signs andamp; Symptoms Pain, Disability, Decreased ROM, Loss of Strength Tests Kendall Thomas Treatment (R.I.C.E.) Rest Ice Compression Elevation NSAIDS Modalities Hydrotherapy US, Diathermy Gentle Stretching? Gradual return to activity.

Muscle Strain: Muscle Strain Avulsions: (Lynch: SM 28(2), 1999) ASIS (Sartorius) AIIS (Rectus Femoris) Ischial Tuberosity (hamstrings) some authors recommend ORIF of Ischial tuberosity fx if large fragment and andgt; 1-2 cm displacement.

Muscle Strain : Muscle Strain Adductor Syndrome (Ch 27 OKU: SM 2 1999) The 'groin' is NOT an individual muscle! Area between thigh and abdominal wall. Muscles: longus, magnus, brevis, pectineus, gracilis Caused by sudden burst of speed, change of direction, or overstretching. Location of pain correlates with recovery Distal takes 1-2 weeks. Proximal takes months, can become chronic.

Muscle Strain: Muscle Strain TREATMENT R.I.C.E. Gentle stretching. Modalities US, TENS, Diathermy. NSAIDS Gentle Stretching. Gradual Return to Activity.

Osteitis Pubis: Osteitis Pubis Chronic inflammatory condition. Common in distance runners and soccer players. Maleandgt;Female 30-40 year olds. Mis-diagnosed as 'groin strain'. Traumatic: Gracilis Syndrome avulsion. Marked by pain in groin AND point tenderness over symphysis pubis, especially resisted adduction. Waddling gait.

Osteitis Pubis : Osteitis Pubis X-rays diastasis, sclerosis, irregular margins Rx: Conservative Rest Ice NSAIDs Physiotherapy Corticosteroid injection --andgt; may take 3-6 months for recovery. Surgical: (Williams: AJSM 28(3), 2000) Fusion of symphysis in patients with instability. 7 rugby players, 2mm displacement, failed 13 mo conservative care. FU 52 months average, all patients asymptomatic. Fusion with plate and screws

Osteitis Pubis: Osteitis Pubis Athletic Pubalgia (Meyers: AJSM 28(1), 2000) Chronic inguinal pain or pubic pain, with radiation down medial thigh. Physical Exam: Pain with adduction against resistance Peri-pubic tenderness Adductor tenderness No hernia. X-rays: Plain films negative. MRI may show fluid at rectus insertion or inflammation of adductors. Rx: Rest Ice Compression NSAIDs

Osteitis Pubis: Osteitis Pubis Athletic Pubalgia (Meyer) Rx (continued) Surgical: Re-attachment of inferior-lateral rectus and release of epimysium of adductor fascia. Review: 276 pts; 176 repairs Sport: soccer(46%), hockey(17%), football(13%), others (24%) Level: high school to professional 95% G/E results in surgical cases 96% performing at or above pre-op level FU on conservative group not available

Hernia: Hernia Inguinal hernia most common overall. Femoral more common in females. Males andgt; Females Physical Exam Painless bulge in groin or scrotum. Reproducible with Valsalva maneuver. Treatment Observation. Support. Surgery.

Hernia: Hernia Athletic Hernia (Lynch: SM 28(2), 1999) Chronic groin pain, no obvious hernia, pain worse with cough, running, kicking Physical Exam: Tender posterior wall of inguinal canal. Occ. bulge of post wall with increased intra-abdominal pressure. Dx: CT vs MRI Rx: Conservative Rest Gradual return to sport Surgical Repair of posterior wall 90% will return back to sport

Nerve Entrapment Syndrome: Nerve Entrapment Syndrome Nerve Entrapment Syndromes (McCrory) Lateral Femoral Cutaneous Nerve Pudendal Nerve Obturator Syndrome Piriformis Syndrome of the sciatic nerve

Lateral Femoral Cutaneous N.: Lateral Femoral Cutaneous N. Sensory innervation to the proximal 2/3 of lateral thigh. No motor innervation. Contusions may result in impaired sensation. Chronic pain due to entrapment in scar tissue. Cortisone/lidocaine injection. Surgical exploration.

Nerve Entrapment Syndromes: Nerve Entrapment Syndromes Piriformis Syndrome (McCrory) Sciatic nerve entrapment by piriformis muscle. Sx: cramping, aching in buttock or hamstrings PE: pain worse with active ER, passive IR and flexion

Piriformis Syndrome: Piriformis Syndrome Cause of lumbar back pain and associated sciatica. Similar presentation as L5 – S1 radiculopathy. 15% of population has sciatic n. passing through the muscle. Pain worse with sitting than with standing. Muscular imbalance. No specific tests for diagnosis. EMG normal unless long standing can see changes if done during provocative maneuvers Include in differential diagnosis for 'sciatica'.

Piriformis Syndrome: Piriformis Syndrome TREATMENT Stretching Activity modification. NSAIDs Surgery?

Inflammatory Conditions: Inflammatory Conditions Bursa – closed fluid filled sac between muscle/bone and muscle/muscle that occur where friction or impingement may occur. Common area where Gluteus medius inserts and IT Band passes over. Female predominance of 2-4:1. Common in runners with increased Q-angles and/or leg length discrepancy. Uneven running surface. May be exacerbated by IT Band Syndrome. Chronically, may result in Snapping Hip Syndrome.

Inflammatory Conditions: Inflammatory Conditions SIGNS andamp; SYMPTOMS Point tenderness Pain w/walking or running, especially up an incline or up stairs. TREATMENT R.I.C.E Gentle Stretching NSAIDS Training modification Lidocaine/ cortisone injection.

Snapping Hip Syndrome: Snapping Hip Syndrome May be benign. Caused by IT band traversing over greater trochanter of femur. Subluxation of the Iliopsoas tendon over lesser trochanter or iliopectineal eminence Common in dancers, gymnasts, hurdlers. Occurs with repetitive motion of lateral rotation and flexion of the hip joint. Early : Trochanteric bursitis. Late : Scarring of bursa. Signs andamp; Symptoms Palpable snap. Audible snap. Muscle imbalance. +/- Pain. Treatment Activity modification. NSAIDs Modalities. Structural movement instruction. Surgical lengthening of tendon vs. excision of bony ridges.

Snapping Hip Syndrome: Snapping Hip Syndrome Internal (Schaberg: AJSM 12(5), 1984) subluxation of the IP tendon over lesser troch. or iliopectineal eminence PE: no greater troch. tenderness, snap with ext. of a FABER hip XR: plain films normal, + iliopsoas bursography (5/6) Rx: Conservative: rest, NSAIDs, stretch, INJ, US Surgical: lengthening of tendon, excision of bony ridges

Snapping Hip Syndrome: Snapping Hip Syndrome Extra-articular (Schaberg: AJSM 12(5), 1984) External thickened anterior margin of GT, snaps over GT PE: tender GT, reproduce snapping Rx: rest, stretching, NSAIDs, US Trochanter Morphology

Ilio-tibial (IT) band Syndrome: Ilio-tibial (IT) band Syndrome

Ilio-tibial (IT) band Syndrome: Ilio-tibial (IT) band Syndrome Tensor fascia latae muscle insertion irritation. Pain over lateral femoral condyle. Causes Tight IT Band. Uneven running surface. Downhill reproduces symptoms. Uphill relieves symptoms. Poor shoewear. Signs andamp; Symptoms Point tenderness. Tests Renne Nobel Ober Treatment R.I.C.E. Modalities. NSAIDS Training modification. Change shoewear. Surgical lengthening +/- GT bursectomy +/- GT osteotomy

Pediatric Hip PathologyLegg Calve-Perthes Syndrome: Pediatric Hip Pathology Legg Calve-Perthes Syndrome Temporary interruption of blood to the proximal femoral epiphysis. Occurs between ages 3-12. Affects boys 3-5x more often than girls. May present with a limp and referred pain to thigh or knee. Stages I – blood supply interrupted to femoral head resulting in pain and stiffness. II – femoral head begins to remodel, new bone cells replace dead cells. III – Continued re-modeling of femoral head into round shape. IV – Normal bone cells replace new bone cells.

Legg Calve-Perthes Syndrome: Legg Calve-Perthes Syndrome TREATMENT Early recognition results in better outcome. Rest Activity modification Physiotherapy Bracing/casting Surgery

Pediatric Hip PathologySlipped Capital Femoral Epiphysis: Pediatric Hip Pathology Slipped Capital Femoral Epiphysis Femoral capital epiphysis displaces off the femoral neck. 'Ice cream scoop slipping off of cone.' Prevelance (Ch 18, OKU Peds 1996) 2-10 occurrences/100,000 Ages Boys: 10-17 years, Girls: 8-15 years Boys 2x andgt; Girls Occurs in overweight adolescents. 50% are andgt; 95th percentile for weight Classification based upon stability and duration. Presents as pain, that may be referred to the thigh or knee. Slow onset of limp.

Slipped Capital Femoral Epiphysis: Slipped Capital Femoral Epiphysis TREATMENT In situ single screw fixation. Protected weightbearing. Physiotherapy.

Stress Fractures: Stress Fractures May occur in pubic rami or femoral neck. Common in marathon type activities. Insidious onset of pain in groin region. Femaleandgt;Male X-rays initially negative. May need MRI to better delineate. Treatment Rest Protected WB Cross training activities.

Stress Fractures: Stress Fractures Femoral Neck Stress Fractures (Johansson: AJSM 18(5), 1990) 90% report groin pain, pain at extremes of ROM, tender in inguinal area X-rays: Plain films negative or sclerosis present, BS + MR +/- Treatment: Tension side: ORIF Compression side: stable, rest, crutches until pain free, gradually increase activity

Stress Fractures: Stress Fractures Pelvic Stress Fractures (Kelly: Military Medicine 165, 2000) Female runner with insidious pain, tenderness over rami. XR: XR +/- Fx line + BS Rx Rest,cross training, protected WB as needed.

Stress Fractures: Stress Fractures Pelvic Stress Fractures (Kelly) Review: 86 patients, 9 wks of training Patients who fractured were shorter, lighter, w/ association with amenorrhea Etiology: pull of adductors on rami Classic Risk factors: advanced age, tobacco use, amenorrhea.

Low Back Pain: Low Back Pain Causes Paraspinous muscle strain/Ligamentous sprain Facet Joint Impingement upon Nerve Root Spinal stenosis Insidious onset rather than acute. Spondylolysis – defect in pars interarticularis. Spondylolisthesis –anterior displacement of vertabrae segment. 'Scotty dog collar' x-ray Disc Injury

Slide51: Spondylolithesis

Low Back Pain: Low Back Pain Diagnostic Lumbar radiographs MRI CT Bone Scan Special Tests Lasegue’s Straight Leg Raise Bowstring Sitting Root Test

Low Back Pain: Low Back Pain L3-L4 disc – L4 nerve root Sensory: posterolateral thigh, ant. knee, medial leg Motor: Quads, hip abductors L4-L5 disc – L5 nerve root Sensory: anterolateral leg, dorsum foot, big toe Motor: EHL, EDL, EDB, Gluteus medius L5-S1 disc – S1 nerve root Sensory: Lat Malleolus, Lateral foot, Heel Motor: Peroneals, Gastroc Soleus, Gluteus Maximus

Low Back Pain: Low Back Pain TREATMENT NSAIDs Physiotherapy Exercises Epidural Injections Surgery Lumbar fusion Laminectomy Discectomy

Subcapital/Femoral Neck FX: Subcapital/Femoral Neck FX

Subcapital/Femoral Neck FX: Subcapital/Femoral Neck FX

Subcapital/Femoral Neck FX: Subcapital/Femoral Neck FX

Subcapital/Femoral Neck FX: Subcapital/Femoral Neck FX

Intertrochanteric Hip FX: Intertrochanteric Hip FX

Intertrochanteric Hip FX: Intertrochanteric Hip FX

Sub-trochanteric Hip FX: Sub-trochanteric Hip FX

Sub-trochanteric Hip FX: Sub-trochanteric Hip FX

Questions?: Questions?

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