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Managing Hip Pain in the
Athlete
Heidi Prather, DO*, Berdale Colorado, DO, MPH, Devyani Hunt, MD
INTRODUCTION
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.
1,2
Hip and groin injuries occur in 5% to 9%
of high school athletes.
3
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.
4
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.
5
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: pratherh@wudosis.wustl.edu
KEYWORDS
Hip Pain Athlete Groin
KEY POINTS
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
http://dx.doi.org/10.1016/j.pmr.2014.06.012 pmr.theclinics.com
1047-9651/14/$ – see front matter Ó2014 Elsevier Inc. All rights reserved.
DIFFERENTIAL DIAGNOSIS
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.
History
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
athletes.
6
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.
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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,
7
including the sacroiliac joints, ischial bursa, and the insertion of the prox-
imal hamstring.
7
The European guidelines for evaluation and treatment of pelvic
Box 1
Differential diagnosis of hip pain
Musculoskeletal hip pain disorders:
Intra-articular
Ligamentum teres tear
Hip dislocation/subluxation/capsular injury
Fracture/stress fracture
Synovitis
Infection
Osteonecrosis of femoral head
Osteochondritis dissecans
Legg-Calve-Perthes disease
Slipped capital femoral epiphysis
Femoroacetabular impingement
Developmental hip dysplasia
Acetabular labral tear
Osteoarthritis
Extra-articular
Hip
Bursitis
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.
8
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.
9
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.
10–12
Patients with FAI also
reported a 23% incidence of low back pain and 12% incidence of posterior thigh
pain.
11
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
region.
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.
13–15
It is most commonly associated with
snapping of the iliotibial band or the gluteus maximus over the greater trochanter
16
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.
16
This snapping often occurs while climbing stairs,
getting out of a car, or rising from a chair.
17
Catching or locking symptoms are also
associated with hip pain and can suggest acetabular labral tear or loose body.
18
In
patients undergoing surgical treatment of acetabular labral tears, 53% report me-
chanical symptoms of popping or snapping, whereas 41% report true locking or
catching.
10
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.
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792
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.
19–26
Asymptomatic elite female
soccer athletes showed variability in hip passive range of motion by age and experi-
ence.
27
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
rotation,
11
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.
28
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
0.59–1.00/0.05–0.75
29
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
0.42–0.81/0.18–0.75
29
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
29
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
0.97/0.11
29
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
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794
Ober test To assess iliotibial band posterior
fiber length
0.41/0.95
30
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
0.41/0.95
30
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
29
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
29
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).
31
Fig. 1. Log roll test.
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796
DIAGNOSTIC IMAGING
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
views.
32,33
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.
32
Fig. 3. FABER/Patrick test.
Prather et al
798
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.
32
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
reliability.
34
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
experts
33
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
33,35
have
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.
35,36
Box 2
Radiographic measurements in FAI
Name of
Measurement or Sign Purpose
Abnormal
Values Description of Measurement
Alpha angle To detect cam-type
deformity
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
deformity
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
retroversion
Presence
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
retroversion
Presence
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
retroversion
Presence
of sign
Sign is present when any portion
of the ischial spine projects
within the pelvic brim
Abbreviation: HNO, head-neck offset.
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For FAI, the maximal bony deformity is commonly located at the anterosuperior
head-neck junction.
37,38
The 45Dunn view best profiles this location.
39
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.
32,33
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).
33
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.
32,33
Global
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.
33
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
802
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.
40
With intra-
articular contrast administration (magnetic resonance arthrography [MRA]), cartilage
lesions and labral tears can adequately be assessed.
41
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.
42
The health care provider
must keep in mind that MRI is especially limited. One study showed 22% sensitivity
43
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,
44
labral
integrity, and labral ossification/acetabular rim bony apposition.
45
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
information.
46,47
Ultrasonography, or sonography, evaluates superficial tendons, muscles, and bursa
about the hip.
48
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.
49
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.
DIAGNOSTIC INTRA-ARTICULAR HIP INJECTION
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.
41
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
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.
28,50
INTRA-ARTICULAR PROCESSES
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
51
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.
52
The 52 patients in the study underwent comprehensive
conservative treatment including patient education, activity modification, a standard-
ized physical therapy protocol
53
that allowed for individualization, and intra-articular
hip injection as indicated for pain control. Patients were followed for 1 year. Pain,
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804
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.
52
Specific
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.
53
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
chondrocytes.
54
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.
33
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.
55,56
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
33
and the inadequacies of surgical
intervention will be realized with time and experience.
57
OA
Research has shown a higher prevalence of hip arthritis in former track athletes
compared with age matched control groups.
58
This association has also been found
in former long distance runners.
59
The cause of this association remains to be
determined, but theories include repetitive trauma and underlying hip deformity
60
contributing to the development of secondary hip OA. However, the literature remains
inconclusive about a causal relationship between running and OA.
61
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.
62
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-
tions.
63
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.
63
Widening of cortical cracks, displacement of fractures, or fractures that do not
respond to conservative treatment generally require surgical stabilization.
64,65
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.
66
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.
64
Most cases are posterior dislocations, accounting for 87% to 93% of
all dislocations.
67
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.
64,68
The incidence
of osteonecrosis increases by as much as 20-fold if the time from injury to reduction is
more than 6 hours.
68
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.
64,68,69
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.
64,68,69
EXTRA-ARTICULAR HIP DISORDERS
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%.
70
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.
71
Physical therapy should focus on addressing the altered lower
extremity biomechanics that are associated with greater trochanteric pain as a result
Prather et al
806
of tensor fascia lata/iliotibial band tightness or pain; hip external rotator strain; and OA
of the spine, hip, or knee.
72
Corticosteroid injections at the greater trochanter and low-
energy shock wave therapy have been found to be effective in multiple studies.
73,74
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.
75
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.
73,74
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.
16
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.
16
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.
76
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.
64,69,76
Antiinflam-
matory medications are often used. Surgery may be considered after 6 to 8 weeks
if these conservative measures fail.
69,76
Both laparoscopic and open surgical tech-
niques have been described, with success in improving symptoms, primarily
through reinforcement of the abdominal wall with mesh.
64
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
noted.
64
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.
77,78
Surgical intervention, including curettage or wedge resection,
may be of benefit if nonoperative measures fail.
76
PRP
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
muscles.
79
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.
SUMMARY
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.
REFERENCES
1. Minnich JM, Hanks JB, Muschaweck U, et al. Sports hernia: diagnosis and
treatment highlighting a minimal repair surgical technique. Am J Sports Med
2011;39(6):1341–9.
2. Quinn A. Hip and groin pain: physiotherapy and rehabilitation issues. Open
Sports Med J 2010;4:93–107.
3. DeLee JC, Farney WC. Incidence of injury in Texas high school football. Am J
Sports Med 1992;20(5):575–80.
4. Yard EE, Schroeder MJ, Fields SK, et al. The epidemiology of United States high
school soccer injuries, 2005-2007. Am J Sports Med 2008;36(10):1930–7.
5. Lovell G. The diagnosis of chronic groin pain in athletes: a review of 189 cases.
Aust J Sci Med Sport 1995;27(3):76–9.
6. Morelli V, Smith V. Groin injuries in athletes. Am Fam Physician 2001;64(8):
1405–14.
7. Stuge B, Garratt A, Krogstad Jenssen H, et al. The pelvic girdle questionnaire:
a condition-specific instrument for assessing activity limitations and symptoms
in people with pelvic girdle pain. Phys Ther 2011;91(7):1096–108.
Prather et al
808
8. Vleeming A, Albert HB, Ostgaard HC, et al. European guidelines for the diagnosis
and treatment of pelvic girdle pain. Eur Spine J 2008;17(6):794–819. http://dx.doi.
org/10.1007/s00586-008-0602-4.
9. Prather H, Hunt D, Fournie A, et al. Early intra-articular hip disease presenting
with posterior pelvic and groin pain. PM R 2009;1(9):809–15.
10. Burnett RS, Della Rocca GJ, Prather H, et al. Clinical presentation of patients
with tears of the acetabular labrum. J Bone Joint Surg Am 2006;88(7):1448–57.
11. Clohisy JC, Knaus ER, Hunt DM, et al. Clinical presentation of patients with
symptomatic anterior hip impingement. Clin Orthop Relat Res 2009;467(3):
638–44.
12. Nunley RM, Prather H, Hunt D, et al. Clinical presentation of symptomatic
acetabular dysplasia in skeletally mature patients. J Bone Joint Surg Am
2011;93(Suppl 2):17–21.
13. Anderson SA, Keene JS. Results of arthroscopic iliopsoas tendon release in
competitive and recreational athletes. Am J Sports Med 2008;36(12):2363–71.
14. Byrd JW. Evaluation and management of the snapping iliopsoas tendon. Instr
Course Lect 2006;55:347–55.
15. Sammarco GJ. The dancer’s hip. Clin Sports Med 1983;2(3):485–98.
16. Lee KS, Rosas HG, Phancao JP. Snapping hip: imaging and treatment. Semin
Musculoskelet Radiol 2013;17(3):286–94.
17. Ilizaliturri VM Jr, Camacho-Galindo J. Endoscopic treatment of snapping hips,
iliotibial band, and iliopsoas tendon. Sports Med Arthrosc 2010;18(2):120–7.
18. Plante M, Wallace R, Busconi BD. Clinical diagnosis of hip pain. Clin Sports Med
2011;30(2):225–38.
19. Aalto TJ, Airaksinen O, Harkonen TM, et al. Effect of passive stretch on repro-
ducibility of hip range of motion measurements. Arch Phys Med Rehabil 2005;
86(3):549–57.
20. Bierma-Zeinstra SM, Bohnen AM, Ramlal R, et al. Comparison between two
devices for measuring hip joint motions. Clin Rehabil 1998;12(6):497–505.
21. Evan R. Illustrated orthopedic physical assessment. 2nd edition. St Louis, MO:
Mosby; 2001.
22. Godges JJ, MacRae PG, Engelke KA. Effects of exercise on hip range of motion,
trunk muscle performance, and gait economy. Phys Ther 1993;73(7):468–77.
23. Hoppenfeld S. Physical examination of the spine and extremities. Norwalk, CT:
Prentice Hall; 1976.
24. Kendall F, McCreary K, Provance P, et al. Muscles: testing and function, with
posture and pain. 5th edition. Baltimore, MD: Lippincott Williams & Wilkins;
2005.
25. Magee D. Orthopedic physical assessment. 4th edition. St Louis, MO: WB Sa-
unders; 2002.
26. Simoneau GG, Hoenig KJ, Lepley JE, et al. Influence of hip position and gender
on active hip internal and external rotation. J Orthop Sports Phys Ther 1998;
28(3):158–64.
27. Prather H, Hunt D, Rho M, et al. Abnormal hip physical examination findings in
asymptomatic female soccer athletes. Knee Surg Sports Traumatol Arthrosc
2013. [Epub ahead of print].
28. Hunt D, Clohisy J, Prather H. Acetabular labral tears of the hip in women. Phys
Med Rehabil Clin N Am 2007;18(3):497–520, ix–x.
29. Reiman MP, Goode AP, Hegedus EJ, et al. Diagnostic accuracy of clinical tests
of the hip: a systematic review with meta-analysis. Br J Sports Med 2013;47(14):
893–902.
Hip Pain 809
30. Fearon AM, Scarvell JM, Neeman T, et al. Greater trochanteric pain syndrome:
defining the clinical syndrome. Br J Sports Med 2013;47(10):649–53.
31. Prather H, Harris-Hayes M, Hunt DM, et al. Reliability and agreement of hip
range of motion and provocative physical examination tests in asymptomatic
volunteers. PM R 2010;2(10):888–95. http://dx.doi.org/10.1016/j.pmrj.2010.
05.005.
32. Clohisy JC, Carlisle JC, Beaule PE, et al. A systematic approach to the plain
radiographic evaluation of the young adult hip. J Bone Joint Surg Am 2008;
90(Suppl 4):47–66.
33. Nepple JJ, Prather H, Trousdale RT, et al. Diagnostic imaging of femoroacetab-
ular impingement. J Am Acad Orthop Surg 2013;21(Suppl 1):S20–6.
34. Carlisle JC, Zebala LP, Shia DS, et al. Reliability of various observers in deter-
mining common radiographic parameters of adult hip structural anatomy.
Iowa Orthop J 2011;31:52–8.
35. Beck M, Leunig M, Parvizi J, et al. Anterior femoroacetabular impingement:
part II. Midterm results of surgical treatment. Clin Orthop Relat Res 2004;
418:67–73.
36. Philippon MJ, Schroder ES, Briggs KK. Hip arthroscopy for femoroacetabular
impingement in patients aged 50 years or older. Arthroscopy 2012;28(1):59–65.
37. Ito K, Minka MA 2nd, Leunig M, et al. Femoroacetabular impingement and the
cam-effect. A MRI-based quantitative anatomical study of the femoral
head-neck offset. J Bone Joint Surg Br 2001;83(2):171–6.
38. Rakhra KS, Sheikh AM, Allen D, et al. Comparison of MRI alpha angle
measurement planes in femoroacetabular impingement. Clin Orthop Relat Res
2009;467(3):660–5.
39. Meyer DC, Beck M, Ellis T, et al. Comparison of six radiographic projections to
assess femoral head/neck asphericity. Clin Orthop Relat Res 2006;445:181–5.
40. Kiuru M, Pihlajamaki HK, Hietanen H, et al. MR imaging, bone scintigraphy, and
radiography in bone stress injuries of the pelvis and the lower extremity. Acta
Radiol 2008;43(2):207–12.
41. Byrd JW, Jones KS. Diagnostic accuracy of clinical assessment, magnetic
resonance imaging, magnetic resonance arthrography, and intra-articular
injection in hip arthroscopy patients. Am J Sports Med 2004;32(7):1668–74.
42. Smith TO, Hilton G, Toms AP, et al. The diagnostic accuracy of acetabular labral
tears using magnetic resonance imaging and magnetic resonance arthro-
graphy: a meta-analysis. Eur Radiol 2011;21(4):863–74.
43. Anderson LA, Peters CL, Park BB, et al. Acetabular cartilage delamination in
femoroacetabular impingement. Risk factors and magnetic resonance imaging
diagnosis. J Bone Joint Surg Am 2009;91(2):305–13.
44. Leunig M, Podeszwa D, Beck M, et al. Magnetic resonance arthrography of
labral disorders in hips with dysplasia and impingement. Clin Orthop Relat
Res 2004;418:74–80.
45. Corten K, Ganz R, Chosa E, et al. Bone apposition of the acetabular rim in deep
hips: a distinct finding of global pincer impingement. J Bone Joint Surg Am
2011;93(Suppl 2):10–6.
46. Beaule PE, Kim YJ, Rakhra KS, et al. New frontiers in cartilage imaging of the
hip. Instr Course Lect 2012;61:253–62.
47. Bittersohl B, Hosalkar HS, Kim YJ, et al. Delayed gadolinium-enhanced
magnetic resonance imaging (dGEMRIC) of hip joint cartilage in femoroace-
tabular impingement (FAI): are pre- and postcontrast imaging both necessary?
Magn Reson Med 2009;62(6):1362–7.
Prather et al
810
48. Blankenbaker DG, De Smet AA, Keene JS. Sonography of the iliopsoas tendon
and injection of the iliopsoas bursa for diagnosis and management of the painful
snapping hip. Skeletal Radiol 2006;35(8):565–71.
49. Jin W, Kim KI, Rhyu KH, et al. Sonographic evaluation of anterosuperior hip
labral tears with magnetic resonance arthrographic and surgical correlation.
J Ultrasound Med 2012;31(3):439–47.
50. Vasudevan JM, Smuck M, Fredericson M. Evaluation of the athlete with buttock
pain. Curr Sports Med Rep 2012;11(1):35–42.
51. Wall PD, Fernandez M, Griffin DR, et al. Nonoperative treatment for femoroacetab-
ular impingement: a systematic review of the literature. PM R 2013;5(5):418–26.
52. Hunt D, Prather H, Harris Hayes M, et al. Clinical outcomes analysis of conser-
vative and surgical treatment of patients with clinical indications of prearthritic,
intra-articular hip disorders. PM R 2012;4(7):479–87.
53. Lewis CL, Sahrmann SA. Acetabular labral tears. Phys Ther 2006;86:110–21.
54. Piper SL, Kramer JD, Kim HT, et al. Effects of local anesthetics on articular
cartilage. Am J Sports Med 2011;39(10):2245–53.
55. Tippett SR. Returning to sports after periacetabular osteotomy for develop-
mental dysplasia of the hip. N Am J Sports Phys Ther 2006;1(1):32–9.
56. van Bergayk AB, Garbuz DS. Quality of life and sports-specific outcomes
after Bernese periacetabular osteotomy. J Bone Joint Surg Br 2002;84(3):
339–43.
57. Jackson TJ, Watson J, Lareau JM, et al. Periacetabular osteotomy and arthro-
scopic labral repair after failed hip arthroscopy due to iatrogenic aggravation
of hip dysplasia. Knee Surg Sports Traumatol Arthrosc 2014;22(4):911–4.
58. Vingard E, Sandmark H, Alfredsson L. Musculoskeletal disorders in former
athletes. A cohort study in 114 track and field champions. Acta Orthop Scand
1995;66(3):289–91.
59. Marti B, Knobloch M, Tschopp A, et al. Is excessive running predictive of degen-
erative hip disease? Controlled study of former elite athletes. BMJ 1989;
299(6691):91–3.
60. Nho S, Kymes S, Callaghan J, et al. The burden of hip osteoarthritis in the United
States: epidemiologic and economic considerations. J Am Acad Orthop Surg
2013;21(suppl 1):S1–6.
61. Willick SE, Hansen PA. Running and osteoarthritis. Clin Sports Med 2010;29(3):
417–28.
62. Johansson C, Ekenman I, Tornkvist H, et al. Stress fractures of the femoral neck
in athletes. The consequence of a delay in diagnosis. Am J Sports Med 1990;
18(5):524–8.
63. Harrast MA, Colonno D. Stress fractures in runners. Clin Sports Med 2010;29(3):
399–416.
64. Anderson K, Strickland SM, Warren R. Hip and groin injuries in athletes. Am J
Sports Med 2001;29(4):521–33.
65. Fullerton LR Jr. Femoral neck stress fractures. Sports Med 1990;9(3):192–7.
66. Nattiv A. Stress fractures and bone health in track and field athletes. J Sci Med
Sport 2000;3(3):268–79.
67. Bastian JD, Turina M, Siebenrok KA, et al. Long-term outcome after traumatic
anterior dislocation of the hip. Arch Orthop Trauma Surg 2011;131(9):1273–8.
68. Kovacevic D, Mariscalco M, Goodwin RC. Injuries about the hip in the adoles-
cent athlete. Sports Med Arthrosc 2011;19(1):64–74.
69. Waite BL, Krabak BJ. Examination and treatment of pediatric injuries of the hip
and pelvis. Phys Med Rehabil Clin N Am 2008;19(2):305–18, ix.
Hip Pain 811
70. Brooker AF Jr. The surgical approach to refractory trochanteric bursitis. Johns
Hopkins Med J 1979;145(3):98–100.
71. Klauser AS, Martinoli C, Tagliafico A, et al. Greater trochanteric pain syndrome.
Semin Musculoskelet Radiol 2013;17(1):43–8.
72. Segal NA, Felson DT, Torner JC, et al. Greater trochanteric pain syndrome:
epidemiology and associated factors. Arch Phys Med Rehabil 2007;88(8):
988–92.
73. Del Buono A, Papalia R, Khanduja V, et al. Management of the greater trochan-
teric pain syndrome: a systematic review. Br Med Bull 2012;102:115–31.
74. Lustenberger DP, Ng VY, Best TM, et al. Efficacy of treatment of trochanteric
bursitis: a systematic review. Clin J Sport Med 2011;21(5):447–53.
75. Moraes VY, Lenza M, Tamaoki MJ, et al. Platelet-rich therapies for musculoskel-
etal soft tissue injuries. Cochrane Database Syst Rev 2013;(12):CD010071.
http://dx.doi.org/10.1002/14651858.CD010071.pub2.
76. Tammareddi K, Morelli V, Reyes M Jr. The athlete’s hip and groin. Prim Care
2013;40(2):313–33.
77. Holt MA, Keene JS, Graf BK, et al. Treatment of osteitis pubis in athletes. Results
of corticosteroid injections. Am J Sports Med 1995;23(5):601–6.
78. O’Connell MJ, Powell T, McCaffrey NM, et al. Symphyseal cleft injection in the
diagnosis and treatment of osteitis pubis in athletes. AJR Am J Roentgenol
2002;179(4):955–9.
79. Nguyen RT, Borg-Stein J, McInnis K. Applications of platelet-rich plasma in
musculoskeletal and sports medicine: an evidence-based approach. PM R
2011;3(3):226–50.
Prather et al
812
