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

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 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. 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

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 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

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

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 of 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 of 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

orthopaedist, 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

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. 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

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

occurs 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

occurs 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