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Hip and groin pain is commonly experienced by athletes. The differential diagnosis should include both intra-articular and extra-articular sources for pain and dysfunction. A comprehensive history and physical examination can guide the evaluation of hip pain and the potential need for further diagnostics. Treatment of athletes with hip disorders includes education, addressing activities of daily living, pain-modulating medications or modalities, exercise and sports modification, and therapeutic exercise. Surgical techniques for prearthritic hip disorders are expanding and can offer appropriate patients a successful return to athletic endeavors when conservative measures are not effective. Copyright © 2014 Elsevier Inc. All rights reserved.
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Managing Hip Pain in the
Heidi Prather, DO*, Berdale Colorado, DO, MPH, Devyani Hunt, MD
Hip and groin pain is commonly experienced by athletes of all ages and activity levels.
Groin pain accounts for 10% of all visits to sports medicine centers and groin injuries
account for up to 6% of all athletic injuries.
Hip and groin injuries occur in 5% to 9%
of high school athletes.
Sports involving increased amounts of acceleration and
deceleration, as well as cutting movements, seem to have increased incidences.
A study of high school soccer injuries reported that 13.3% of all injuries sustained
by girls involved the hip and thigh.
Causes of hip and groin pain can often be compli-
cated by the overlapping signs and symptoms of other disorders, as well as the
complex anatomy and biomechanics of the hip. Furthermore, many hip and groin
injuries have multiple components or coexisting injuries.
This article reviews the
causes of hip pain in athletes, provides a clinical approach for accurate diagnosis,
and discusses treatment options for common hip disorders.
Disclosures: None declared.
Department of Orthopaedic Surgery, Washington University School of Medicine, 660 South
Euclid Avenue, Campus Box 8233, St Louis, MO 63110, USA
* Corresponding author.
E-mail address:
Hip Pain Athlete Groin
Hip and groin pain is commonly experienced by athletes.
The differential diagnosis is extensive and should include both intra-articular and extra-
articular sources for pain and dysfunction.
Evaluation for the underlying disorder can be complicated.
A comprehensive history and physical examination can guide the evaluation of hip pain
and the potential need for further diagnostics such as imaging or diagnostic hip injection.
Treatment of athletes with hip disorders includes education, addressing activities of daily
living, pain-modulating medications or modalities, exercise and sports modification, and
therapeutic exercise.
Phys Med Rehabil Clin N Am 25 (2014) 789–812
1047-9651/14/$ – see front matter Ó2014 Elsevier Inc. All rights reserved.
The differential diagnosis for athletes presenting with hip pain is extensive and can span
multiple medical specialties and disciplines. For example, an athlete whose technique
of running has altered because of a hip injury may begin to experience pain in other
areas, including the pelvic girdle, lumbar spine, and knee. Both musculoskeletal and
nonmusculoskeletal sources of hip pain must be considered (Box 1). These nonmuscu-
loskeletal sources may include visceral structures of the abdomen and pelvis.
It is important for the sports medicine provider to distinguish between intra-articular
versus extra-articular sources of hip pain (see Box 1), which is accomplished through
a complete evaluation, including a thorough history and physical examination, along
with appropriate diagnostic testing.
The medical history for a patient presenting with hip pain should include age, onset
(and mechanism of injury, if applicable), distribution, quality, severity, progression,
exacerbating factors, alleviating factors, and other associated signs/symptoms.
The differential diagnosis for hip pain can vary based on the age of the athlete. In the
pediatric and adolescent athlete presenting with hip and groin pain, consideration
should be given to apophyseal injuries, Legg-Calve-Perthes disease, and slipped
capital femoral epiphysis. In contrast, older athletes are often affected by osteoar-
thritis (OA) of the hip.
Hip pain with acute onset has a distinct differential diagnosis from hip pain that is
chronic or of insidious onset. A detailed mechanism of injury should be elicited with
hip pain of acute onset. For example, sudden forceful muscle contractions (particularly
eccentric) often result in muscle strains or tears in adults and apophyseal avulsions in
adolescents. The adductor muscles are often involved, particularly in soccer, football,
and hockey athletes. Adductor strain is the most common cause of groin pain in
Further, fracture should be considered in athletes with sudden onset of
pain associated with a specific event. The event may not have seemed to be signifi-
cant enough to cause a bony fracture, but athletes with an underlying bone minerali-
zation deficit may become symptomatic with a seemingly benign event.
The distribution of hip pain is wide and variable but should be assessed by
the health care provider to assist in making a diagnosis and to reassess following
treatment. Anterior groin pain is often associated with intra-articular hip disorders.
These disorders include femoral or acetabular fracture, avascular necrosis, OA, syno-
vitis, ligamentum teres tear, and prearthritic hip disorders (isolated acetabular labral
tears, developmental hip dysplasia [DDH], and femoroacetabular impingement
[FAI] with and without acetabular labral tears). Extra-articular sources associated
with anterior groin pain include the pubic rami, iliopsoas, adductor group, and abdom-
inal muscles. Sports hernia typically involves injury to the abdominal muscles, partic-
ularly the external oblique muscle and aponeurosis, with possible injury to the
adductors. In addition to the muscles and surrounding soft tissues, higher lumbar
radiculopathy should also be considered as a source of an athlete’s groin pain.
Lateral hip pain can be associated with intra-articular hip disorders, including all of
those listed for anterior distribution of pain. In isolation, lateral hip pain is often asso-
ciated with extra-articular disorders, including greater trochanteric bursitis or greater
trochanteric pain syndrome, which may include gluteus medius or minimus tendinop-
athy, or pain related to tensor fascia lata/iliotibial band dysfunction. Lumbar spine
disorders, particularly those involving the L4 to L5 distribution, can present with lateral
hip pain.
Prather et al
Posterior pelvic pain is the area of great overlap between the hip, pelvic girdle, and
lumbar spine and is not fully understood. Multiple structures contribute to posterior
pelvic pain,
including the sacroiliac joints, ischial bursa, and the insertion of the prox-
imal hamstring.
The European guidelines for evaluation and treatment of pelvic
Box 1
Differential diagnosis of hip pain
Musculoskeletal hip pain disorders:
Ligamentum teres tear
Hip dislocation/subluxation/capsular injury
Fracture/stress fracture
Osteonecrosis of femoral head
Osteochondritis dissecans
Legg-Calve-Perthes disease
Slipped capital femoral epiphysis
Femoroacetabular impingement
Developmental hip dysplasia
Acetabular labral tear
Muscle strain/tendinopathy/tear: gluteus medius/minimus, piriformis, adductors, rectus
femoris, iliopsoas, rectus abdominis, proximal hamstrings, tensor fascia lata
Greater trochanteric pain syndrome
Snapping hip syndrome
Regional musculoskeletal
Pubic ramus stress fracture/osteitis pubis
Sports hernia/pubalgia
Lumbar spine: facet joint pain, lumbosacral radiculopathy
Sacroiliac joint dysfunction
Peripheral nerve entrapment: genitofemoral, iliohypogastric, ilioinguinal, lateral femoral
cutaneous, obturator, pudendal, superior and inferior gluteal
Nonmusculoskeletal hip pain disorders:
Gastrointestinal: appendicitis, diverticulitis, lymphadenitis, inflammatory bowel disease,
inguinal/femoral hernia
Genitourinary: endometriosis, prostatitis, urinary tract infection, pelvic inflammatory
disease, ovarian cysts, nephrolithiasis, ectopic pregnancy
Pelvic tumor
Hip Pain 791
girdle pain continue to provide a comprehensive resource for understanding the
relationships of the pelvic girdle and lumbar spine and include diagnostic and ther-
apeutic evidence-based reviews.
Increased tone, fatigue, or dysfunction of the
hip abductors, extensors, lateral rotators, and the lumbopelvic fascia are confound-
ing factors. Lumbar spine disorders also commonly present with pain in the posterior
pelvis and can range from structural and physiologic changes of the intervertebral
disc, facet joint, and central or foraminal canal, ranging from L1 to S1 myotome
and dermatome levels. Less understood is the role of the hip in posterior pelvic
pain. In a previous descriptive study, 20% of patients successfully treated with hip
arthroscopy for acetabular labral tears in isolation with pain unresponsive to conser-
vative treatment reported posterior pelvic pain as part of the distribution of pain
before surgery.
In a series of descriptive studies, posterior pelvic pain was reported
by patients before surgery in 17.3% of patients with DDH, 29% of patients with FAI,
and 38% of patients with isolated acetabular labral tears.
Patients with FAI also
reported a 23% incidence of low back pain and 12% incidence of posterior thigh
Lumbar spine, pelvic girdle, and hip disorders can present with a variety of
distributions of pain that overlap across regions. Recognizing this overlap in the
distribution of symptoms enables the sports medicine provider to consider an under-
lying hip disorder in athletes with isolated groin pain as well as in the lumbopelvic
Pain quality, severity, progression, exacerbating factors, and alleviating factors
provide additional information to narrow the differential diagnosis. Burning pain is
often associated with a neuropathic cause. Pain with active contraction or passive
stretch of a particular muscle suggests a tendinopathy or muscle strain/tear. Symp-
toms that are worse with coughing or sneezing and causing an increase in intra-
abdominal and intraspinal pain may suggest an intervertebral disc or abdominal or
inguinal hernia as a source of pain.
Specific motions or weight bearing associated with snapping, catching, or lock-
ing can be associated with extra-articular and intra-articular hip disorders. Snap-
ping hip is commonly associated with hip pain and has been estimated to occur
in 5% to 10% of the general population, but is especially seen in athletes such
as soccer players, runners, weight lifters, and dancers who perform significant
hip flexion and extension movements.
It is most commonly associated with
snapping of the iliotibial band or the gluteus maximus over the greater trochanter
that occurs during return to full extension of the hip. Another common cause of
anterior snapping hip is aberrant movement of the iliopsoas tendon snapping
over the iliopectineal eminence.
This snapping often occurs while climbing stairs,
getting out of a car, or rising from a chair.
Catching or locking symptoms are also
associated with hip pain and can suggest acetabular labral tear or loose body.
patients undergoing surgical treatment of acetabular labral tears, 53% report me-
chanical symptoms of popping or snapping, whereas 41% report true locking or
Neurologic deficits in strength and sensation imply nerve root damage (radiculop-
athy) or peripheral nerve entrapment. Affected nerves can include the obturator,
pudendal, superior gluteal, inferior gluteal, genitofemoral, iliohypogastric, ilioinguinal,
and lateral femoral cutaneous nerves. Past surgical history may often be associated
with peripheral nerve entrapments.
Providers should be aware of signs and symptoms that may indicate nonmus-
culoskeletal sources of hip pain, including various gastrointestinal and genitourinary
disorders. Further questioning regarding bowel and bladder function, sexual activity,
and menstrual history should be considered.
Prather et al
Physical Examination
The physical examination for hip pain should be guided by each athlete’s history.
In general, it should include inspection, range of motion, palpation, a neurologic exam-
ination, and provocative hip testing.
Inspection should assess seated and standing postures, transfers, ability to bear
weight, and gait. Areas of asymmetry, including muscle atrophy or masses, should
be noted. Antalgic and asymmetric movements with transfers and gait should also
be noted to help further characterize the underlying disorder. Foot position preference
in standing and with ambulation should be noted because it is an initial indicator of
pain, bony abnormality, and/or soft tissue adaptation or restriction. Observing a Tren-
delenburg gait gives the sports medicine provider an initial impression of gluteal weak-
ness that has implications for dysfunctions across regions including the lumbar spine,
pelvic girdle, and hip.
Active and passive range of motion of the hip should be performed, assessing for
asymmetries from side to side and available end range. Hip range-of-motion para-
meters are variable in the literature. Age, gender, bony deformity, and soft tissue laxity
and restrictions can all influence hip range of motion but are not consistently
controlled for in studies assessing active and passive hip range of motion, which likely
contributes to the variability of reported normal.
Asymptomatic elite female
soccer athletes showed variability in hip passive range of motion by age and experi-
Specific hip disorders have been found to be associated with patterns of
reduced hip range of motion. Patients with FAI have reduced hip flexion and internal
whereas those with hip OA may first experience reduced hip internal
rotation and progress to a loss of motion in all planes. Active range of motion of the
lumbar spine should be performed to assess whether pain is provoked in a specific
direction, which may help determine whether a spine disorder is contributing to the
constellation of symptoms associated with a hip disorder.
Palpation of relevant anatomic structures (as described earlier) of the lumbar
spine, posterior pelvis, lateral hip, and anterior groin can help identify underlying dis-
orders when pain is provoked or asymmetries are palpated in the bony and soft tis-
sue structures. Dynamic palpation tests can also be used, such as palpation of the
inguinal canal during coughing in the setting of a possible inguinal hernia. Abdominal
hernia can be assessed by palpation of the abdominal muscle insertion in the
midline on the superior pubis insertion during lower abdominal contraction. If an
asymmetrical fullness is noted with pain at the time of contraction versus at rest,
abdominal hernia becomes a consideration. Palpation of the iliopsoas tendon with
concentric and eccentric contraction may elicit the pain and the snap. Likewise,
palpation of the iliotibial band during hip flexion and abduction may provoke a pain-
ful snap.
Evaluation of strength and length in the muscles about the hip can identify areas of
movement system breakdown that may be contributing to the patient’s hip pain. For
example, extra-articular muscle imbalances between posterior hip abductors and
external rotators in combination with shortened hip flexors and iliotibial band can
lead to groin and lateral hip pain.
A neurologic examination consisting of sensory, motor, reflex, and neural tension
provocative tests can further assess neurologic involvement in the patient’s hip
pain. If any of the neurologic examination tests are positive, regional sources for
pain in the pelvis and lumbar spine should be considered.
Several provocative hip tests can help assess intra-articular versus extra-articular
hip disorders (Table 1). None are specific enough to be used in isolation but collective
Hip Pain 793
Table 1
Provocative tests of the hip
Name of Test Purpose Sensitivity/Specificity Description of Test
Anterior hip impingement test To assess hip disorder, impingement,
or anterior superior labral tear
Patient lies supine. Examiner passively flexes
hip and knee, internally rotates and
adducts hip. A positive test reproduces
anterior or lateral hip pain
Patrick test or FABER test To discern between hip, sacroiliac
joint, and low back disorders
Patient lies supine. Examiner places the ankle
of the test leg just above the opposite knee
in the position shown in Fig. 4. The
opposite ASIS is stabilized with one hand
and the other hand applies pressure to the
test leg’s knee toward the table. A positive
test for sacroiliac joint or low back disorder
reproduces posterior pelvic pain
Resisted straight leg raise test or
Stinchfield test
To assess hip disorder 0.59/0.32
Patient lies supine and actively flexes hip
with knee extended to 30against
resistance. A positive test reproduces
anterior or lateral hip pain
Log roll test To assess hip disorder Unavailable Patient lies supine with hips and knees
extended. Examiner passively internally
and externally rotates test leg while
stabilizing knee and ankle so that motion
occurs at the hip. A positive test
reproduces anterior or lateral hip pain
Posterior hip impingement test To assess hip disorder, posterior
labral test
Patient lies prone with hip and knee
extended. Examiner passively extends,
adducts, and externally rotates hip. A
positive test reproduces anterior hip or
posterior pelvic pain
Prather et al
Ober test To assess iliotibial band posterior
fiber length
Patient lies on side. Lower leg is flexed at the
hip and knee. Examiner passively extends
the patient’s upper leg with the knee
flexed at 90. While supporting the knee,
the examiner slowly lowers the leg. If the
iliotibial band is shortened, the leg remains
abducted and does not fall to the table
To assess iliotibial band anterior
fiber length
Patient lies on side. Lower leg is flexed at the
hip and knee. Examiner passively flexes the
patient’s upper limb hip with the knee
flexed at 90. While supporting the knee,
the examiner slowly lowers the leg. If the
iliotibial band is shortened, the leg remains
abducted and does not fall to the table
Thomas test To assess hip flexor contracture 0.89/0.92
Patient sits at the edge of table. Patient
flexes 1 knee to chest and rolls onto back
while allowing test leg to remain extended
at the hip off the edge of the table. If the
hip does not fully extend, this indicates hip
flexion contracture. If the leg abducts, this
indicates iliotibial band tightness
Trendelenburg sign To assess hip abductor strength 0.23–0.97/0.77–0.96
Patient is standing. Examiner places hands on
top of the iliac crests and monitors. Patient
stands on the affected leg in a single-leg
stance. Test/sign is positive if pelvis droops
on the unaffected side, which indicates hip
abductor weakness on the side of the
stance leg
Abbreviation: FABER, flexion, abduction, external rotation.
Hip Pain 795
assessment can help direct further diagnostic evaluation and treatment. The log roll
test, anterior hip impingement, and flexion, abduction, external rotation (FABER)/Pat-
rick test have been shown to have high inter-rater agreement in asymptomatic young
adults (Figs. 1 and 2).
Fig. 1. Log roll test.
Prather et al
Many hip disorders are diagnosed by history and physical examination. However,
imaging can confirm a diagnosis and reveal or rule out other possible structural
entities. Plain radiographs are typically the first-line imaging method to assess hip
pain. They are useful for detecting osseous abnormalities, including fractures, OA,
Fig. 2. Anterior hip impingement test.
Hip Pain 797
and intra-articular bodies. Radiographic views that best evaluate the hip include
anteroposterior (AP) pelvis, false-profile, Dunn, frog-lateral, and cross-table lateral
In general, the AP pelvis (Fig. 3) and false-profile views provide the most
information regarding acetabular morphology, and the lateral and Dunn (Fig. 4) views
provide the most information regarding the proximal femur.
Fig. 3. FABER/Patrick test.
Prather et al
Radiographs remain the best way to assess bony hip structure. There are several
measurements used to describe bony structure and hip deformity (Box 2). Examiners
should be aware that these measurements can be adequately assessed only with
standardized, high-quality radiographs with proper positioning of the patient.
Examples of measurements including the alpha angle, femoral head and neck offset
Fig. 4. Resisted straight leg test.
Hip Pain 799
ratio, and cross-over sign are shown in Figs. 5–8. Hip expert examiners from different
practices have not shown high inter-rater reliability for these common measurements,
but inexperienced examiners trained by one expert showed good inter-rater
The cutoff points for normal range of measurements and deformity have
varied in the past but a recent consensus review by an international group of hip
suggested the current range of cutoffs for FAI and hip OA (see Box 2). Using
this range of cutoffs for specific measurements, an estimated 8% to 13% of asymp-
tomatic male patients and 2% to 7% of asymptomatic female patients
measurements on hip radiographs consistent with FAI. As a result, the determination
of hip deformity does not uniformly determine the athlete’s source of pain and
dysfunction. OA found on plain radiographs of the hip has important implications on
counseling and management of the athlete with intra-articular hip pain. The Tonnis
grade or Kellgren-Lawrence scale are commonly used to describe the extent of OA
based on the presence and degree of joint space narrowing, osteophytes, sclerosis,
and subchondral cysts. It is important to delineate the extent of degenerative change
in an athlete’s hip. Athletes with a Tonnis grade 2 or higher are poor candidates for hip
preservation surgery.
Box 2
Radiographic measurements in FAI
Name of
Measurement or Sign Purpose
Values Description of Measurement
Alpha angle To detect cam-type
63First, determine best-fit circle to
the femoral head. First arm of
the angle is drawn from the
center of the femoral neck to
the center of the femoral head.
Second arm is drawn from the
center of the femoral head to
the point where the femoral
head-neck junction extends
beyond the margin of the circle
HNO To detect cam-type
8 mm First, determine axis of the femoral
neck. Then, 2 parallel lines are
drawn to the femoral neck axis
at the anterolateral edge of the
femoral head and at the
anterolateral aspect of the
femoral neck. The distance
between these 2 lines define the
femoral HNO
Crossover sign To detect acetabular
of sign
Sign is present when the anterior
wall projects lateral to the
posterior wall before
converging at the lateral
acetabular sourcil
Posterior wall sign To detect acetabular
of sign
Sign is present when the center of
the femoral head is located
lateral to the posterior wall
Ischial spine sign To detect acetabular
of sign
Sign is present when any portion
of the ischial spine projects
within the pelvic brim
Abbreviation: HNO, head-neck offset.
Prather et al
For FAI, the maximal bony deformity is commonly located at the anterosuperior
head-neck junction.
The 45Dunn view best profiles this location.
The standing
AP pelvis, false-profile, and Dunn views are the preferred series in the young athletic
population. This combination allows the practitioner to make the appropriate
measurements to assess for FAI and DDH with the least amount of radiation.
The quantitative radiographic measurements used most commonly for detecting
a cam-type deformity in FAI are the alpha angle (see Fig. 3) and the head-neck offset
ratio (see Fig. 4).
The radiographic evaluation of pincer-type deformity in FAI focuses
on the detection of acetabular retroversion with the presence or absence of a cross-
over sign (see Fig. 5), posterior wall sign, and prominent ischial spine sign.
acetabular coverage, a form of pincer-type FAI, is evaluated with measurement of the
lateral center edge angle as well as the presence or absence of acetabular protrusion
or coxa profunda.
Fig. 5. Lateral frog leg of the hip.
Hip Pain 801
Fig. 6. AP view of the pelvis showing the center of edge angle of Wiberg.
Fig. 7. (A) AP view of the pelvis, which allows appropriate hip measurements. (B) Appropriate
positioning for AP view of the pelvis with attention to positioning of the lower extremities. (C)
Appropriate positioning for anterior posterior view of the pelvis with attentionto positioning
of the anterior superior iliac spine (ASIS).
Prather et al
Magnetic resonance imaging (MRI) can detect abnormal soft tissue disorders of a
tendon, muscle, or bursa and can assess the degree of degenerative changes or early
avascular necrosis to a greater extent than radiographic imaging. It is also becoming
the imaging study of choice for the evaluation of bony stress injuries.
With intra-
articular contrast administration (magnetic resonance arthrography [MRA]), cartilage
lesions and labral tears can adequately be assessed.
A meta-analysis comparing
conventional MRI with MRA in the detection of acetabular labral tears found MRA
superior to MRI, with a sensitivity of 87% and specificity of 64% for MRA compared
with a sensitivity of 66% and specificity of 79% for MRI.
The health care provider
must keep in mind that MRI is especially limited. One study showed 22% sensitivity
in its ability to detect acetabular cartilage flaps or delamination lesions, which often
accompany labrochondral junction injuries. MRI provides a description of the anatomy
Fig. 8. (A) Bilateral Dunn view. (B) Lateral frog hip view. (C) Patient position for the frog view.
Hip Pain 803
of the acetabulum, including acetabular version, acetabular depth, labral size,
integrity, and labral ossification/acetabular rim bony apposition.
Biochemical MRI
and delayed gadolinium-enhanced MRI of cartilage are being investigated to detect
early changes in cartilage, and these are likely to lead to more detailed diagnostic
Ultrasonography, or sonography, evaluates superficial tendons, muscles, and bursa
about the hip.
The dynamic real-time potential of ultrasonography, including sono-
palpation, is an advantage compared with static plain radiographs and MRI. This
advantage may be particularly helpful in the case of a snapping hip. However, ultra-
sonography has difficulty with evaluating deep structures in which visibility can be
reduced based on patient size. Ultrasonography has lesser diagnostic ability than
MRA in the detection of anterosuperior acetabular labral tears. One study found the
sensitivity and specificity of ultrasonography to be 82% and 60%, respectively,
whereas the sensitivity and specificity of MRA were 91% and 80%, respectively.
Despite this reduced specificity and sensitivity, using ultrasonography in the athletic
population can be useful in the acute setting of symptoms because of its low cost
and potential ease of access. However, if symptoms persist and a cause remains un-
determined or requires confirmation, more sensitive and specific imaging modalities
should be used.
A diagnostic hip injection should be considered to confirm an intra-articular process. A
positive response to an intra-articular diagnostic injection is 90% predictive of intra-
articular disorder found at arthroscopy.
A diagnostic (anesthetic only) injection
that provides relief in symptoms and resolution of provocative hip tests paired with
MRI/MRA that shows deformity with or without a labral tear can help confirm the
intra-articular source of pain.
Management of select hip disorders encountered in athletes (divided by intra-articular
and extra-articular processes) is presented later. In general, the treatment of hip pain
involves reduction of pain, activity modification, movement retraining, and progression
to return to sport with implementation of a maintenance program.
Prearthritic Hip Disorders
There are limited data on the outcomes of comprehensive conservative care of
athletes with prearthritic hip disorders that include symptomatic DDH and FAI with
and without acetabular labral tears. A recent systematic review of nonoperative treat-
ment of symptomatic FAI by Wall and colleagues
found only 5 studies that
reviewed treatment, and 2 of the 5 specifically described treatment. The investigators
concluded that, with limited experimental data, there is a suggestion that physical
therapy and activity modification are of benefit to patients. One of the studies that
specifically described treatment described patients with history, physical examina-
tion, and imaging findings consistent with intra-articular hip disorders with and
without mild deformity.
The 52 patients in the study underwent comprehensive
conservative treatment including patient education, activity modification, a standard-
ized physical therapy protocol
that allowed for individualization, and intra-articular
hip injection as indicated for pain control. Patients were followed for 1 year. Pain,
Prather et al
function, and progression to surgery were measured. Patients treated with conserva-
tive treatment alone compared with those who chose to have surgical intervention
following conservative treatment showed similar improvements in pain and function
at 1 year. Baseline pain, function, and degree of deformity did not affect outcome at
1 year. The only statistically significant differences between the two groups were that
the group of patients who chose surgery was more active at baseline.
therapeutic exercises have not been determined or fully studied for these disorders.
Some therapeutic approaches for treatment are designed to reduce anteriorly
directed forces on the hip by addressing the patterns of recruitment of muscles
that control hip motion, by correcting the movement patterns during exercises
such as hip extension and gait, and by instruction in the avoidance of pivotingmo-
tions in which the acetabulum rotates on the femur, particularly under load. In partic-
ular, the control of the hip abductor, deep lateral rotator, gluteus maximus, and
iliopsoas muscles should be optimized and dominant involvement of the quadriceps
femoris and hamstring muscles should be corrected.
The specifics of appropriate
conservative treatment have not been definitively determined. However, athletes
with prearthritic hip disorders need education regarding the mechanisms involved
in the disorder. Activity modification plays a major role and includes activities other
than exercise and sports. Evaluation of the athlete’s technique is imperative in modi-
fying symptoms during sports. Although image-guided intra-articular corticosteroid
injections can help modify pain in athletes with early OA, steroid injections should
be avoided in this prearthritic population to minimize potential damage to
When comprehensive conservative management of the athlete has been attempted
without satisfactory improvement, surgical intervention should be considered. With
recent advances in hip arthroscopy techniques, more is known about the surgical
options for these patients.
When mixed deformity is present, arthroscopy may not
be an option and more extensive hip preservation surgery such as surgical dislocation
or periacetabular osteotomy may be indicated.
The inherent goals of these
surgical procedures are to reduce pain, improve function, and correct bony deformity
with the hope of reducing the progression of hip OA. However, as expected with new
interventions, patient selection is imperative
and the inadequacies of surgical
intervention will be realized with time and experience.
Research has shown a higher prevalence of hip arthritis in former track athletes
compared with age matched control groups.
This association has also been found
in former long distance runners.
The cause of this association remains to be
determined, but theories include repetitive trauma and underlying hip deformity
contributing to the development of secondary hip OA. However, the literature remains
inconclusive about a causal relationship between running and OA.
Athletes with
intra-articular hip pain, hip deformity, and secondary arthritis of Tonnis grade 2 or
more have poor outcomes with hip preservation surgery. Therefore optimizing con-
servative measures is the first choice of treatment. Activity modification to avoid
painful range of motion during sport, activities of daily living, and therapeutic exercise
is essential. These patients may also benefit from a trial of glucosamine and
chondroitin, medication regimens for pain control including acetaminophen and
nonsteroidal antiinflammatory drugs, and intra-articular image-guided corticosteroid
injections to modify pain and therefore improve function. Surgical intervention with
hip resurfacing or total hip arthroplasty is a viable option in athletes with end stage
arthritis not controlled with conservative measures.
Hip Pain 805
Femoral Neck Stress Fracture
The major focus of treatment of femoral stress fractures is to avoid preventable
complications. In one report of a series of athletes treated for femoral stress fractures,
30% had a complication, including nonunion, malunion, osteonecrosis, and develop-
ment of OA.
Treatment of the stress fracture is determined by the location. Stress
fractures on the tension side of the femoral neck, involving the superior portion, often
require internal fixation because of potential instability and high rate of complica-
Compression side stress fractures involving the inferomedial femoral neck
are typically treated conservatively with reduction in weight bearing for 6 to 8 weeks
and graded return to activity. Frequent radiographic monitoring is recommended for
possible progression, given the high rate of complications, and to confirm healing.
Widening of cortical cracks, displacement of fractures, or fractures that do not
respond to conservative treatment generally require surgical stabilization.
During the period of rest following diagnosis of stress fracture, use of crutches may
be indicated initially if ambulation is antalgic. Oral analgesics may be required. Once
the patient has achieved pain-free activities of daily living, then a gradual return to
sport may be initiated. Treatment of the stress fracture should also include addressing
any predisposing or contributing factors, such as low bone mineral density, menstrual
dysfunction, and low energy availability (including inadequate calcium and vitamin D
intake), especially in the female athlete.
In addition, any related training errors and
biomechanical factors should be addressed.
Hip Dislocation/Subluxation
Although rare, dislocation of the hip may be caused by a collision in contact sports or
in snow skiing.
Most cases are posterior dislocations, accounting for 87% to 93% of
all dislocations.
The dislocated hip requires emergent treatment in order to minimize
the risk of complications. The most common complication is osteonecrosis, but nerve
injury, acetabular labral tears, and chondral injuries may also occur.
The incidence
of osteonecrosis increases by as much as 20-fold if the time from injury to reduction is
more than 6 hours.
After neurovascular assessment, closed reduction under
conscious sedation is the initial treatment. In some cases, general anesthesia may
be required. Open reduction is indicated if closed reduction is unsuccessful after
2 or 3 attempts, or if loose intra-articular osteochondral fragments or interposed
soft tissue are present.
Following reduction, treatment involves protected
weight bearing with crutches, followed by gradual range of motion, strengthening,
and return to activity for a total of 6 to 8 weeks.
Greater Trochanteric Pain Syndrome
Greater trochanteric pain typically responds to conservative measures, including
activity modification, physical therapy, antiinflammatory medications, ice/heat, and
corticosteroid injection. Success rates for these conservative measures, either alone
or in combination, can exceed 90%.
However, recurrence is common. In these
cases, further evaluation to investigate the mechanism of the breakdown in the
musculoskeletal system is imperative to find a point of resolution or, at a minimum,
a reliable maintenance program; this is especially the case for greater trochanteric
pain, because it is commonly caused by more than an isolated trochanteric bursitis.
Microtrauma leading to tears of the hip abductor tendons may be the leading cause
of this syndrome.
Physical therapy should focus on addressing the altered lower
extremity biomechanics that are associated with greater trochanteric pain as a result
Prather et al
of tensor fascia lata/iliotibial band tightness or pain; hip external rotator strain; and OA
of the spine, hip, or knee.
Corticosteroid injections at the greater trochanter and low-
energy shock wave therapy have been found to be effective in multiple studies.
Tendon damage or rupture is a potential complication of corticosteroid injections,
and possible short-term benefits from repeated injections should be weighed against
potential long-term risks. Platelet-rich plasma (PRP) has gained attention in recent
years for soft tissue injuries, especially in athletes. However, at this time there is no
evidence to support their use for greater trochanteric pain.
Several surgical pro-
cedures are available for greater trochanteric pain that is unresponsive to conservative
measures, such as iliotibial band release or lengthening, bursectomy, or trochanteric
reduction osteotomy.
Snapping Hip Syndrome
There is overlap between the treatment of greater trochanteric pain syndrome and
extra-articular snapping hip syndrome. Most cases of extra-articular snapping hip
can be treated conservatively with activity modification, physical therapy, and antiin-
flammatory medications. If conservative measures fail, corticosteroid injections
targeting either the iliopsoas bursa or underneath the iliotibial band over the greater
trochanter may be beneficial.
Ultrasonography guidance is often used with these
injections because of ease of visualization of muscle tendon junctions and tendon
insertion points. Surgical treatments are available for extra-articular snapping hip, if
conservative measures and injections fail; however the surgical techniques described
are limited because of the limited number of patients requiring surgery.
Muscle Strain/Tear
Muscle strains or tears involving the hip and groin typically involve the hip adductor
muscles, as well as the iliopsoas, quadriceps, and hamstring muscles. Initial treatment
of muscle strains and partial tears includes rest, ice, compressive wrap, and antiin-
flammatory medications. Gentle range-of-motion exercises may begin after pain
subsides, followed by strengthening exercises and gradual return to activity. Athletes
with acute strains typically return to sport within 4 to 8 weeks, with recovery time as
long as 6 months with chronic strains.
Progression of strains to partial tears, and
partial tears to complete tears, may be a consequence of inadequate healing time.
Surgical repair is typically indicated with complete tears.
Sports Hernia
Pain associated with posterior abdominal wall insufficiency and abnormalities is
initially treated with conservative measures including rest from sport, followed by
stretching and strengthening of the hip and lower abdomen.
matory medications are often used. Surgery may be considered after 6 to 8 weeks
if these conservative measures fail.
Both laparoscopic and open surgical tech-
niques have been described, with success in improving symptoms, primarily
through reinforcement of the abdominal wall with mesh.
Treatment of the coexist-
ing contracted or overdeveloped adductor longus muscle ipsilaterally may also be
required via adductor muscle release, particularly if adductor muscle pain is
Osteitis Pubis
The initial treatment of this pubic bone stress injury includes conservative measures,
including rest, stretching of the involved muscles/tendons, and antiinflammatory
medications. A prolonged healing course of more than 3 months may be required,
Hip Pain 807
with occasional recurrence. Corticosteroid injection may be considered if conserva-
tive measures fail.
Surgical intervention, including curettage or wedge resection,
may be of benefit if nonoperative measures fail.
Musculoskeletal and sports medicine applications for the therapeutic use of PRP have
received significant attention over the past decade. With regard to hip disorders, PRP
has been proposed in the treatment of chronic ligamentous injury, chronic tendinop-
athy, and muscle tears, especially in the proximal hamstring, gluteal, and adductor
Although regenerative medicine is promising, the scientific literature on
PRP remains in its infancy and the optimal injection technique and most efficacious
injectate preparation remain uncertain. The role of PRP and other orthobiologics is
discussed in further detail by Drs Mautner and Kneer elsewhere in this issue.
Hip and groin pain is commonly experienced by athletes. The differential diagnosis is
extensive and should include both intra-articular and extra-articular sources for pain
and dysfunction. Further, evaluation for the underlying disorder can be complicated.
A comprehensive history and physical examination can guide the evaluation of
hip pain and the potential need for further diagnostics such as imaging or diagnostic
hip injection. Treatment of athletes with hip disorders includes education, addressing
activities of daily living, pain-modulating medications or modalities, exercise and
sports modification, and therapeutic exercise. Advice on a graded return to exercise
and sport is imperative for successful outcomes with athletes and reduction of recur-
rence of symptoms. Surgical techniques for prearthritic hip disorders are expanding
and can offer appropriate patients a successful return to athletic endeavors when
conservative measures are not effective. Further studies to determine appropriate
conservative treatment are vital to improve patient outcomes, offer athletes more
choices for treatment, and potentially improve overall surgical outcomes as patient
selection becomes more focused.
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Prather et al
... Hip and groin pain is a common complaint among athletes of all ages and has been estimated to account for 5% to 6% of all sports injuries. 31,49 The cause of hip and groin pain is often multifactorial, including bony and soft tissue abnormalities that can occur intra-or extra-articularly in both the acute and chronic overuse settings. 4,13,20,35,49 A study by Packer and Safran 47 in 2015 suggested that there may be a genetic predisposition toward hip abnormalities, with white patients noted to have higher rates of hip injuries, such as femoroacetabular impingement (FAI), than Asian patients. ...
... 31,49 The cause of hip and groin pain is often multifactorial, including bony and soft tissue abnormalities that can occur intra-or extra-articularly in both the acute and chronic overuse settings. 4,13,20,35,49 A study by Packer and Safran 47 in 2015 suggested that there may be a genetic predisposition toward hip abnormalities, with white patients noted to have higher rates of hip injuries, such as femoroacetabular impingement (FAI), than Asian patients. Additionally, there is evidence that younger athletes participating in high-impact sports have an increased risk of developing cam-type deformities and eventual osteoarthritis. ...
... One major issue is the difficulty of diagnosis, particularly in the acute setting, because many hip disorders present with overlapping signs and symptoms that are nonspecific and difficult to assess. 4,49,52 Complex pathomechanical interactions within the hip joint and the central watershed location of the hip often result in a vague clinical picture without an obvious diagnosis. 20 Athletes can also develop a compensatory secondary dysfunction such as trochanteric bursitis, which further complicates the clinical picture. ...
Full-text available
Background Hip and groin pain is a common complaint among athletes. Few studies have examined the epidemiology of hip and groin injuries in collegiate athletes across multiple sports. Purpose To describe the rates, mechanisms, sex-based differences, and severity of hip/groin injuries across 25 collegiate sports. Study Design Descriptive epidemiology study. Methods Data from the 2009-2010 through 2013-2014 academic years were obtained from the National Collegiate Athletic Association Injury Surveillance Program (NCAA ISP). The rate of hip/groin injuries, mechanism of injury, time lost from competition, and need for surgery were calculated. Differences between sex-comparable sports were quantified using rate ratios (RRs) and injury proportion ratios (IPRs). Results In total, 1984 hip/groin injuries were reported, giving an overall injury rate of 53.06 per 100,000 athlete-exposures (AEs). An adductor/groin tear was the most common injury, comprising 24.5% of all injuries. The sports with the highest rates of injuries per 100,000 AEs were men’s soccer (110.84), men’s ice hockey (104.90), and women’s ice hockey (76.88). In sex-comparable sports, men had a higher rate of injuries per 100,000 AEs compared with women (59.53 vs 42.27, respectively; RR, 1.41 [95% CI, 1.28-1.55]). The most common injury mechanisms were noncontact (48.4% of all injuries) and overuse/gradual (20.4%). In sex-comparable sports, men had a greater proportion of injuries due to player contact than women (17.0% vs 3.6%, respectively; IPR, 4.80 [95% CI, 3.10-7.42]), while women had a greater proportion of injuries due to overuse/gradual than men (29.1% vs 16.7%, respectively; IPR, 1.74 [95% CI, 1.46-2.06]). Overall, 39.3% of hip/groin injuries resulted in time lost from competition. Only 1.3% of injuries required surgery. Conclusion Hip/groin injuries are most common in sports that involve kicking or skating and sudden changes in direction and speed. Most hip/groin injuries in collegiate athletes are noncontact and do not result in time lost from competition, and few require surgery. This information can help guide treatment and prevention measures to limit such injuries in male and female collegiate athletes.
... Anterior hip pain is a common complaint among young athletes, with a reported incidence rate ranging from 10 to 70% in this population [1][2][3][4]. Anterior hip pain accounts for 10% of all sports medicine visits for young athletes [1]. Female high school soccer players commonly sustain hip injuries, with 13% of all injuries attributed to this joint [1]. ...
... Anterior hip pain is a common complaint among young athletes, with a reported incidence rate ranging from 10 to 70% in this population [1][2][3][4]. Anterior hip pain accounts for 10% of all sports medicine visits for young athletes [1]. Female high school soccer players commonly sustain hip injuries, with 13% of all injuries attributed to this joint [1]. ...
... Anterior hip pain accounts for 10% of all sports medicine visits for young athletes [1]. Female high school soccer players commonly sustain hip injuries, with 13% of all injuries attributed to this joint [1]. Among the elite, approximately 70% of soccer players reported hip/groin pain during one season [4]. ...
Objectives: The purposes of this study were to: (1) assess the benefit of adding manual therapy (MT) to physical therapy care in pediatric patients with anterior hip pain; (2) assess the relative risk of adverse reactions when MT is used; and (3) report the types of MT used. Methods: This study was a retrospective chart review of patients treated in a hospital-based sports medicine clinic. The charts of 201 patients (mean age = 14.23 ± 2.15 years) met the inclusion criteria and were reviewed. Patients were grouped into those who received MT during their episode of care, and those who did not. Pain efficiency (change in pain/number of visits), number and type of adverse reactions, as well as frequency and type of manual therapy interventions used, were the outcomes of interest. Results: The mean pain efficiency was significantly less if manual therapy was performed (MT = 0.60 [95% CI 0.47–0.72], no MT = 0.80 [95% CI 0.71–0.90] p = 0.01). There was no significant difference between groups in risk of adverse reactions (MT = 5, no MT = 5). The number of visits was significantly different between groups (MT = 9.43 ± 3.9 sessions, and no MT = 7.6 ± 5.2 sessions). Discussion: MT did not increase the risk of an adverse reaction in pediatric patients with anterior hip pain. While it appears to be a safe intervention, it did not improve pain efficiency or patient adherence. Future research should be performed to assess the effectiveness of MT, when performed by skilled therapists, in pediatric patients with hip pain in a controlled manner. Level of Evidence: 3b.
... Appropriate conservative care for these disorders has not been determined, and to date only 2 studies have prospectively described specific conservative care and outcomes [66,67]. A standardized nonoperative treatment protocol for these athletes has not yet been definitively determined, but descriptive reviews [68][69][70] and case reports [71,72] support the observation that in some cases, even athletes with labral tears can improve symptomatically and return to a satisfactory level of competition without surgery. A systematic review of outcomes for nonoperative management of FAI found that 3 of 5 studies showed favorable results. ...
... Radiographic measurements to evaluate for femoroacetabular impingement determine the axis of the femoral neck; then 2 lines are drawn parallel to the femoral neck axis: one at the anterolateral edge of the femoral head, and one at the anterolateral aspect of the femoral neck; the distance between these 2 lines is the femoral HNO The first arm of the angle is a line parallel to the transverse axis of the pelvis and crosses through the inferomedial aspect of the acetabular sourcil (the sclerotic weight-bearing zone of the acetabulum); the second arm connects the medial and lateral aspects of the acetabular sourcil; too small an angle suggests a pincer-type deformity, and too large an angle suggests dysplasia Lateral center-edge angle (of Wiberg)AP pelvis <25 or 40 The first arm of the angle is a line perpendicular to the transverse axis of the pelvis and crosses through the center of the femoral head; the second arm connects the center of the femoral head with the most superolateral point of the acetabular sourcil; too large an angle suggests a pincer-type deformity, and too small an angle suggests dysplasia Anterior center-edge angle <20The first arm of the angle is a vertical line drawn through the center of the femoral head; the second arm connects the center of the femoral head with the most anterior point of the acetabular sourcilThe sign is present when the anterior wall projects lateral to the posterior wall before converging at the lateral acetabular sourcilThe sign is present when the center of the femoral head is located lateral to the posterior wallThe sign is present when any portion of the ischial spine projects within the pelvic brim AP ¼ anteroposterior; CT ¼ computed tomography; MRI ¼ magnetic resonance imaging; HNO ¼ head-neck offset. Adapted from Prather[69]. ...
Full-text available
Evaluation of an athlete's report of “hip pain” is challenging. Many conditions involving the pelvic girdle can present with overlapping pain distributions, and athletes often may have coexisting disorders. Appropriate evaluation requires thorough, systematic consideration of intra-articular hip disease, extra-articular local causes of hip pain, and referred pain from other musculoskeletal or even visceral sources. Although our understanding of intra-articular hip disorders has been greatly enhanced in recent decades through advances in hip arthroscopy, gaps still exist in our understanding of appropriate treatment, including effective nonsurgical protocols and when to consider surgical intervention. For instance, we have a better understanding of hip dysfunction related to structural changes that occur prior to the onset of arthritis, but we are also learning that correction of the structural changes does not always guarantee a correction of dysfunction and pain. Furthermore, athletes need instruction and guidance in retraining appropriate movement patterns after a surgical intervention. Risk stratification regarding which athletes need surgical intervention and what their needs are after specific surgical procedures remain undefined. In this review we will describe the differential diagnosis of hip and pelvic girdle pain in the athlete and then discuss how to use a history, physical examination, and appropriate imaging and diagnostic injections to arrive at a proper diagnosis. Lastly, a brief discussion is included of key concepts and controversies involved in treating some of the most common hip disorders experienced by athletes.
... Estima-se que lesões do quadril são responsáveis por 5 a 6% das lesões esportivas. 28,29 No esporte universitário americano, uma taxa de 53,06 lesões por 100.000 exposiçõesatleta foi reportada. 30 Porém, estes estudos incluem lesões musculares na epidemiologia de lesões do quadril, não separando lesões articulares. ...
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Resumo O impacto femoroacetabular (IFA) é uma importante causa de dor no quadril, e a principal etiologia da osteoartrose do quadril no jovem. O IFA é caracterizado por alterações sutis da anatomia do acetábulo e do fêmur proximal que podem causar lesões do complexo condrolabial. O lábio é uma estrutura fibrocartilaginosa essencial na estabilidade articular. Três tipos de IFA são descritos: came (onde há uma anesfericidade da cabeça femoral), pincer (onde há uma sobrecobertura acetabular) e misto (que apresenta características de ambos). A etiologia do IFA está relacionada com características genéticas e ambientais. O conhecimento desta doença e sua fisiopatologia é essencial para o tratamento de pacientes que apresentam dor no quadril.
Background: Athletic pubalgia (AP) is an increasingly recognized injury among young athletes. This study aimed to evaluate the characteristics associated with AP in college football players. Hypothesis: Repetitive explosive movements that require aggressive core muscle activation results in AP in collegiate football players. Study design: Retrospective cohort design. Level of evidence: Level 3. Methods: Football student-athletes at a single Division I collegiate institution from January 2010 to December 2019 were included in the study. The primary outcome measure was surgery for AP. The odds of AP were determined using logistic regression, with the dependent variable being whether or not the student-athlete received AP surgery. Independent variables included Olympic weightlifting (OWL) exposure, primary playing position (skill position vs nonskill position), and body mass index (BMI). Results: A total of 1154 total student-athlete exposures met the inclusion criteria. Of the 576 student-athletes exposed to OWL (OWL occurred throughout entire calendar year), 20 developed AP, whereas 7 student-athletes not exposed to OWL (OWL was not performed at any point during calendar year) developed AP. Student-athletes exposed to OWL had a 2.86 (95% CI, 1.25-7.35; P = 0.02) times higher odds of AP than players not exposed after controlling for primary playing position and BMI. Skill position players had a 9.32 (95% CI, 1.71-63.96; P = 0.01) times higher odds of AP than nonskill position players when controlling for BMI and OWL training. Conclusion: Modifiable factors that increase exposure to repetitive explosive activities, such as OWL and playing a skill position, may be important considerations in developing AP. Clinical relevance: The cause of AP is multifactorial and poorly understood. Identifying factors associated with AP informs athletes, athletic trainers, physicians, and coaches.
Background: Long-standing groin pain syndrome (LSGPS) is a form of groin pain syndrome in which the cohort of symptoms reported by patients is experienced for a long period, typically for over 12 weeks, and is recalcitrant to any conservative therapy. The aim of this prospective epidemiological study was to describe the clinical causes of LSGPS in 37 female athletic subjects in Italy through the Groin Pain Syndrome Italian Consensus Conference on terminology, clinical evaluation and imaging assessment in groin pain in athletes classification and guidelines. Methods: Thirty-seven female athletes affected by LSGPS were evaluated following the guidelines issued by the Groin Pain Syndrome Italian Consensus Conference on terminology, clinical evaluation and imaging assessment of groin pain in athletes. Results: In the considered population, each patient presented only one pathological cause for LSGPS. The most frequent aetiologies were inguinal pathologies (54.05% of the cases), acetabular labrum tear (18.92%) and pelvic floor disorders (8.11%). Adductor tendinopathy represented only 2.70% of cases. Conclusions: Female athletic patients affected by LSGPS show a similar incidence of inguinal and hip pathologies as in male populations. However, these clinical situations do not seem to be associated in women unlike in the male population. This difference is probably due to particular anatomical differences related to gender. For this reason, women affected by LSGPS represent an important subset of patients. Moreover, adductor tendinopathy is probably overrated as an etiopathogenetic source of LSGPS in women.
Lower extremity joint pain is extremely common, affecting 50% of people in the United States older than 18 years and 75% of those older than 65, and causes significant disability, lost work days, and decreased quality of life. Many patients presenting to pain management physicians suffer from lower extremity joint issues. This chapter provides a review of the anatomy, physiology, and biomechanics of lower extremity joints including the hip, knee, and ankle and describes common joint pathologies ranging from osteoarthritis to various ligamentous injuries. Lastly it delves into treatments, including interventional pain procedures.
Despite being relatively uncommon when compared to injuries to the ankle and knee, hip injuries in the contact athlete account for 5%-6% of all athletic-related injuries with increasing prevalence over the last decade. Athletic hip injuries represent a spectrum of often overlapping intra- and extra-articular disorders with the potential to cause significant disability and time lost from sport. Advancements in imaging modalities, arthroscopic instrumentation, and surgical techniques have improved diagnostic capabilities and treatment outcomes of athletic hip injuries. Furthermore, increased screening and better recognition of the role of femoroacetabular impingement on the development of intra-articular hip pathology and instability has provided physicians with a treatable risk factor deterring further hip disorders. This chapter provides physicians with a brief overview of commonly encounter hip injuries in the contact athlete, namely: muscle strains, contusion, labral injuries, and hip instability secondary to dislocation or subluxation in the setting of femoroacetabular impingement, as well as the previously described “sports hip triad.”
Visceral and somatic causes of pelvic pain are often inter-related, and a musculoskeletal examination should always be considered for the successful diagnosis and treatment of pelvic pain. For the diverse etiologies of hip pain, there are many unique considerations for the diagnosis and treatment of these various disorders. Pelvic pain is often multidimensional due to the overlap between lumbo-hip-pelvic diagnoses and may require a multidisciplinary approach to evaluation and management.
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Imaging studies play a key role in establishing the diagnosis of femoroacetabular impingement (FAI). When clinical examination is suggestive of FAI, radiographic evidence should confirm the diagnosis. Imaging findings must be evaluated in the context of the patient's clinical presentation and recreational activities. Plain radiographic evaluation remains the initial diagnostic modality. Three-dimensional imaging such as MRI and CT often is obtained for the evaluation of labral and cartilage pathology, definition of bony anatomy, and surgical planning.
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Examination of the hip provides information regarding risk for pre-arthritic hip disorders, knee injuries, and low back pain. The purpose of this study was to report a hip screening examination of asymptomatic female soccer athletes and to test the hypothesis that these findings vary by competition experience. Asymptomatic females from a youth soccer club, a college, and a professional team were evaluated. Passive hip range of motion, hip abduction strength, and hip provocative tests were assessed. Data were compared for the grade/middle school, high school, college, and professional athletes. One hundred and seventy-two athletes with a mean age of 16.7 ± 5 years (range 10-30) participated. Professional athletes had less flexion (HF) for both hips (p < 0.0001) and less internal rotation (IR) for the preferred kicking leg (p < 0.05) compared to all other groups. Grade/middle school athletes had more external rotation in both hips as compared to all other groups (p < 0.0001). For the preferred kicking leg, collegiate athletes had less hip abduction strength as compared to other groups (p < 0.01). Positive provocative hip tests were found in 22 % of all players and 36 % of the professionals. In professionals, a positive provocative test was associated with ipsilateral decreased HF (p = 0.04). Asymptomatic elite female soccer athletes with the most competition experience had less bilateral hip flexion and preferred kicking leg IR than less-experienced athletes. Positive provocative hip tests were found in 22 % of athletes. Future studies are needed to show whether these findings link to risk for intra-articular hip or lumbar spine and knee disorders. LEVEL OF EVIDENCE: III.
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Hip arthroscopy can be a successful surgery when properly indicated and performed properly. In the setting of dysplasia, arthroscopy of the hip can lead to devastating consequences. This case presents a patient who underwent hip arthroscopy despite having significant hip dysplasia. The surgery failed and was subsequently revised with a concomitant arthroscopic labral repair and periacetabular osteotomy with good results at 2-year follow-up. Level of evidence Case report, Level IV.
General Introduction Anatomy of the Spine Vasculature of the Spine Basic neurology Upper / Lower motor neuron disease testing musculature reflex sensation, temperature, pain, vibration, and grading systems cervical eye examination thoracic spine examination lumbar examination
Osteoarthritis (OA) is a common and disabling disease. Because of improved treatment of chronic diseases and lower mortality from infectious diseases, the US population is aging, and older Americans are living with disabling conditions, including hip OA. The projected number of older adults with arthritis or other chronic musculoskeletal joint symptoms is expected to nearly double, from 21.4 million in 2005 to 41.1 million by 2030. The burden of hip OA is increasing due to the aging population and the obesity crisis; as a result, the need for total hip arthroplasty (THA) is expected to grow 174%, to 572,000 primary THAs per year by 2030 in the United States. Prior projections appear to have underestimated the actual number of primary and revision THAs that are in demand.
Background: The clinical presentation of a labral tear of the acetabulum may be variable, and the diagnosis is often delayed. We sought to define the clinical characteristics associated with symptomatic acetabular labral tears by reviewing a group of patients who had an arthroscopically confirmed diagnosis. Methods: We retrospectively reviewed the records for sixty-six consecutive patients (sixty-six hips) who had a documented labral tear that had been confirmed with hip arthroscopy. We had prospectively recorded demographic factors, symptoms, physical examination findings, previous treatments, functional limitations, the manner of onset, the duration of symptoms until the diagnosis of the labral tear, other diagnoses offered by health-care providers, and other surgical procedures that these patients had undergone. Radiographic abnormalities and magnetic resonance arthrography findings were also recorded. Results: The study group included forty-seven female patients (71%) and nineteen male patients (29%) with a mean age of thirty-eight years. The initial presentation was insidious in forty patients, was associated with a low-energy acute injury in twenty, and was associated with major trauma in six. Moderate to severe pain was reported by fifty-seven patients (86%), with groin pain predominating (sixty-one patients; 92%). Sixty patients (91%) had activity-related pain (p < 0.0001), and forty-seven patients (71%) had night pain (p = 0.0006). On examination, twenty-six patients (39%) had a limp, twenty-five (38%) had a positive Trendelenburg sign, and sixty-three (95%) had a positive impingement sign. The mean time from the onset of symptoms to the diagnosis of a labral tear was twenty-one months. A mean of 3.3 health-care providers had been seen by the patients prior to the definitive diagnosis. Surgery on another anatomic site had been recommended for eleven patients (17%), and four had undergone an unsuccessful operative procedure prior to the diagnosis of the labral tear. At an average of 16.4 months after hip arthroscopy, fifty-nine patients (89%) reported clinical improvement in comparison with the preoperative status. Conclusions: The clinical presentation of a patient who has a labral tear may vary, and the correct diagnosis may not be considered initially. In young, active patients with a predominant complaint of groin pain with or without a history of trauma, the diagnosis of a labral tear should be suspected and investigated as radiographs and the history may be nonspecific for this diagnosis. Level of Evidence: Diagnostic Level IV. See Instructions to Authors for a complete description of levels of evidence.
Diss. med. Bern. Literaturverz. Sonderdr. aus: The journal of bone & joint surgery (Br) ; vol. 83-B, no. 2, March 2001.
Platelet-rich therapies are being used increasingly in the treatment of musculoskeletal soft tissue injuries such as ligament, muscle and tendon tears and tendinopathies. These therapies can be used as the principal treatment or as an augmentation procedure (application after surgical repair or reconstruction). Platelet-rich therapies are produced by centrifuging a quantity of the patient's own blood and extracting the active, platelet-rich, fraction. The platelet-rich fraction is applied to the injured tissue; for example, by injection. Platelets have the ability to produce several growth factors, so these therapies should enhance tissue healing. There is a need to assess whether this translates into clinical benefit. To assess the effects (benefits and harms) of platelet-rich therapies for treating musculoskeletal soft tissue injuries. We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (25 March 2013), the Cochrane Central Register of Controlled Trials (CENTRAL 2013 Issue 2), MEDLINE (1946 to March 2013), EMBASE (1980 to 2013 Week 12) and LILACS (1982 to March 2012). We also searched trial registers (to Week 2 2013) and conference abstracts (2005 to March 2012). No language or publication restrictions were applied. We included randomised and quasi-randomised controlled trials that compared platelet-rich therapy with either placebo, autologous whole blood, dry needling or no platelet-rich therapy for people with acute or chronic musculoskeletal soft tissue injuries. Primary outcomes were functional status, pain and adverse effects. Two review authors independently extracted data and assessed each study's risk of bias. Disagreement was resolved by discussion or by arbitration by a third author. We contacted trial authors for clarification of methods or missing data. Treatment effects were assessed using risk ratios for dichotomous data and mean differences (MD) or standardised mean differences (SMD) for continuous data, together with 95% confidence intervals. Where appropriate, data were pooled using the fixed-effect model for RR and MD, and the random-effects model for SMD. The quality of the evidence for each outcome was assessed using GRADE criteria. We included data from 19 small single centre trials (17 randomised and two quasi-randomised; 1088 participants) that compared platelet-rich therapy with placebo, autologous whole blood, dry needling or no platelet-rich therapy. These trials covered eight clinical conditions: rotator cuff tears (arthroscopic repair) (six trials); shoulder impingement syndrome surgery (one trial); elbow epicondylitis (three trials); anterior cruciate ligament (ACL) reconstruction (four trials), ACL reconstruction (donor graft site application) (two trials), patellar tendinopathy (one trial), Achilles tendinopathy (one trial) and acute Achilles rupture surgical repair (one trial). We also grouped trials into 'tendinopathies' where platelet-rich therapy (PRT) injections were the main treatment (five trials), and surgical augmentation procedures where PRT was applied during surgery (14 trials). Trial participants were mainly male, except in trials including rotator cuff tears, and elbow and Achilles tendinopathies.Three trials were judged as being at low risk of bias; the other 16 were at high or unclear risk of bias relating to selection, detection, attrition or selective reporting, or combinations of these. The methods of preparing platelet-rich plasma (PRP) varied and lacked standardisation and quantification of the PRP applied to the patient.We were able to pool data for our primary outcomes (function, pain, adverse events) for a maximum of 11 trials and 45% of participants. The evidence for all primary outcomes was judged as being of very low quality.Data assessing function in the short term (up to three months) were pooled from five trials that assessed PRT in three clinical conditions and used four different measures. These showed no significant difference between PRT and control (SMD 0.24; 95% confidence interval (CI) -0.07 to 0.56; P value 0.13; I² = 35%; 273 participants; positive values favour PRT). Medium-term function data (at six months) were pooled from six trials that assessed PRT in five clinical conditions and used six different measures. These also showed no difference between groups (SMD 0.06; 95% CI -0.39 to 0.51; P value 0.79; I² = 64%; 262 participants). Long-term function data (at one year) were pooled from 10 trials that assessed PRT in five clinical conditions and used six different measures. These also showed no difference between groups (SMD 0.25, 95% CI -0.07 to 0.57; P value 0.12; I² = 66%; 484 participants). Although the 95% confidence intervals indicate the possibility of a slightly poorer outcome in the PRT group up to a moderate difference in favour of PRT at short- and long-term follow-up, these do not translate into clinically relevant differences.Data pooled from four trials that assessed PRT in three clinical conditions showed a small reduction in short-term pain in favour of PRT on a 10-point scale (MD -0.95, 95% CI -1.41 to -0.48; I² = 0%; 175 participants). The clinical significance of this result is marginal.Four trials reported adverse events; another seven trials reported an absence of adverse events. There was no difference between treatment groups in the numbers of participants with adverse effects (7/241 versus 5/245; RR 1.31, 95% CI 0.48 to 3.59; I² = 0%; 486 participants).In terms of individual conditions, we pooled heterogeneous data for long-term function from six trials of PRT application during rotator cuff tear surgery. This showed no statistically or clinically significant differences between the two groups (324 participants). Pooled data for short-term function for three elbow epicondylitis trials (179 participants) showed a statistically significant difference in favour of PRT, but the clinical significance of this finding is uncertain.The available evidence is insufficient to indicate whether the effects of PRT will differ importantly in individual clinical conditions. Overall, and for the individual clinical conditions, there is currently insufficient evidence to support the use of PRT for treating musculoskeletal soft tissue injuries. Researchers contemplating RCTs should consider the coverage of currently ongoing trials when assessing the need for future RCTs on specific conditions. There is need for standardisation of PRP preparation methods.
Snapping hip, or coxa saltans, presents as an audible or palpable snapping that occurs around the hip during movement and can be associated with or without pain. The prevalence of snapping hip is estimated to occur in up to 10% of the general population, but it is especially seen in athletes such as dancers, soccer players, weight lifters, and runners. Although the snapping sound can be readily heard, the diagnostic cause may be a clinical challenge. The causes of snapping hip have been divided into two distinct categories: extra-articular and intra-articular. Extra-articular snapping hip can be further subdivided into external and internal causes. Advances in imaging techniques have improved the diagnostic accuracy of the various causes of snapping hip, mainly by providing real-time imaging evaluation of moving structures during the snapping phase. Image-guided treatments have also been useful in the diagnostic work-up of snapping hip given the complexity and multitude of causes of hip pain. We discuss the common and uncommon causes of snapping hip, the advanced imaging techniques that now give us a better understanding of the underlying mechanism, and an image-guided diagnostic and therapeutic algorithm that helps to identify surgical candidates.
Groin and hip injuries are seen in athletes who perform quick directional changes and cutting movements. Because forces generated through athletic performance are transferred through the hip, injuries to these areas may limit athletes with mild pain or lead to career-ending injuries. The anatomy of the hip and groin is complex and symptoms often overlap. This article discusses some athletic causes, but other medical conditions may be associated with hip and groin pain as well. Updates in evaluation and treatment are discussed for adductor strains, hip osteoarthritis, femoroacetabular impingement, sports hernia, osteitis pubis, and obturator nerve entrapment.