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Ischiofemoral Impingement and Hamstrings Syndrome Distal Causes of Deep Gluteal Syndrome

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  • Baylor University Medical Center at Dallas
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... Although more studies are still required to confirm this, it has been suggested that anatomic variations in the femoroacetabular joint could cause pain referred to the hip or in the proximal insertion of the hamstrings and develop compensations in the kinematics of running [62]. In this context, it has been reported that the pattern of neuromuscular coordination (muscle activations patterns) of gait varies according to walking at slow speeds [63], so it could be suggesting that these patterns would also change at running speeds. ...
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Hamstring tear injuries (HTI) are the most prevalent injuries in athletes, with high reinjury rates. To prevent reinjury and reduce the severity of injuries, it is essential to identify potential risk factors. Hip characteristics are fundamental to optimal hamstring function. We sought to investigate the role of hip joint clearance discrepancy (JCD) as a risk factor for HTI and a clinical predictor of risk of reinjury and injury severity. A cross-sectional, retrospective study was performed with elite athletes (n = 100) who did (n = 50) and did not (n = 50) have a history of injury. X-rays were taken to assess JCD. We reviewed muscular lesions historial, and health records for the previous 5 years. Significant differences were found in injury severity (p = 0.026; ŋ2p = 0.105) and a number of injuries (p = 0.003; ŋ2p = 0.172). The multivariate analysis data indicated that JCD was significantly associated with the number of injuries and their severity (p < 0.05). In the stepwise regression model, JCD variability explained 60.1% of the number of injuries (R2 0.601) and 10.5% of injury severity (R2 0.0105). These results suggest that JCD could play an important role as a risk factor for HTI and also as a clinical predictor of reinjury and injury severity.
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Deep gluteal syndrome is an increasingly recognized disease entity, caused by compression of the sciatic or pudendal nerve due to non-discogenic pelvic lesions. It includes the piriformis syndrome, the gemelli-obturator internus syndrome, the ischiofemoral impingement syndrome, and the proximal hamstring syndrome. The concept of the deep gluteal syndrome extends our understanding of posterior hip pain due to nerve entrapment beyond the traditional model of the piriformis syndrome. Nevertheless, there has been terminological confusion and the deep gluteal syndrome has often been undiagnosed or mistaken for other conditions. Careful history-taking, a physical examination including provocation tests, an electrodiagnostic study, and imaging are necessary for an accurate diagnosis. After excluding spinal lesions, MRI scans of the pelvis are helpful in diagnosing deep gluteal syndrome and identifying pathological conditions entrapping the nerves. It can be conservatively treated with multidisciplinary treatment including rest, the avoidance of provoking activities, medication, injections, and physiotherapy. Endoscopic or open surgical decompression is recommended in patients with persistent or recurrent symptoms after conservative treatment or in those who may have masses compressing the sciatic nerve. Many physicians remain unfamiliar with this syndrome and there is a lack of relevant literature. This comprehensive review aims to provide the latest information about the epidemiology, aetiology, pathology, clinical features, diagnosis, and treatment. Cite this article: Bone Joint J 2020;102-B(5):556–567.
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Terminal hip flexion contributes to increased strain in peripheral nerves at the level of the hip joint. The effects of hip abduction and femoral version on sciatic nerve biomechanics are not well understood. A decrease in sciatic nerve strain will be observed during terminal hip flexion and hip abduction, independent of femoral version. Six un-embalmed human cadavers were utilized. Three Differential Variable Reluctance Transducers (DVRTs) sensors were placed on the sciatic nerve while the leg was flexed to 70° with a combination of − 10°, 0°, 20° and 40° adduction/abduction. DVRT placement included: (i) under piriformis, (ii) immediately distal to the gemelli/obturator, (iii) four centimeters distal to sensor two. A de-rotational osteotomy to decrease femoral version 10° was performed, and sciatic nerve strain was measured by the same procedure. Data were analyzed with three-way analysis of variance and Bonferroni post-hoc analysis to identify differences in the mean values of sciatic nerve strain between native and decreased version state, hip abduction angle and DVRT sensor location. Significant main effects were observed for femoral version (P = 0.04) and DVRT sensor location (P = 0.01). Sciatic nerve strain decreased during terminal hip flexion and abduction in the decreased version state. An 84.23% decrease in sciatic nerve strain was observed during hip abduction from neutral to 40° in the presence of decreased version at terminal hip flexion. The results obtained from this study confirm the role of decreased femoral version and hip abduction at terminal hip flexion to decrease the strain in the sciatic nerve.
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Purpose: To establish the accuracy of the long-stride walking (LSW) and ischiofemoral impingement (IFI) tests for diagnosing IFI in patients whose primary symptom is posterior hip pain. Methods: Confirmed IFI cases and cases in which IFI had been ruled out were identified considering imaging, injections, and endoscopic assessment, combined with pain relief and negative IFI-specific tests after treatment. Demographic data, duration of symptoms, pain location, ischiofemoral space, quadratus femoris space, quadratus femoris edema, surgical findings, and visual analog scale score for pain before and after treatment were computed for all patients included in this study. Sensitivity, specificity, predictive values, likelihood ratios, and diagnostic odds ratios were computed individually for the LSW test and IFI test. Results: Cases from 1,166 consecutive hip operations and charts from 564 consecutive outpatients were retrospectively reviewed to identify patients who underwent injection and/or endoscopic surgery because of posterior hip pain. Thirty individuals (21 women and 9 men) with a mean age of 49.8 years (range, 20 to 76 years; standard deviation, 13.0 years) were included for analysis. Of the 30 patients, 17 (56.6%) were confirmed as positive for IFI and 13 (43.4%) were confirmed as negative for IFI. The IFI test had a sensitivity of 0.82, specificity of 0.85, positive predictive value of 0.88, negative predictive value of 0.79, positive likelihood ratio of 5.35, negative likelihood ratio of 0.21, and diagnostic odds ratio of 25.6. The LSW test had a sensitivity of 0.94, specificity of 0.85, positive predictive value of 0.89, negative predictive value of 0.92, positive likelihood ratio of 6.12, negative likelihood ratio of 0.07, and diagnostic odds ratio of 88.8. Conclusions: In patients with complaints of posterior hip pain and negative evaluation findings for lumbosacral spine involvement or static/dynamic mechanical axis malalignment, the IFI and LSW tests are highly accurate to help identify those with or without IFI. LEVEL OF EVIDENCE: Level III, diagnostic study.
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The purpose of this study is to quantify the lesser trochanteric version and determine the angle and the relationship between lesser trochanter and femoral neck version. Investigate the influence of the lesser trochanter version in the width of ischiofemoral space. Two hundred and fifty asymptomatic hips were evaluated with axial magnetic resonance image. The lesser trochanter version was calculated. The difference between the femoral neck version and the lesser trochanter version formed the angle between each structure. The width of ischiofemoral space was measured and its relationship with the lesser trochanter version was determined. The mean lesser trochanter version was -24° ± 11.5° (range, - 54° to + 17°) with a coefficient variation of 47.45%. The mean femoral neck version measured 14.0° ± 10.8° (range, -16° to 50°), with a coefficient variation of 81.32%. The lesser trochanter/femora neck angle was 38.4° ± 9.6° (range, 8° to 67°), coefficient variation of 30%, with a moderate correlation between the structures (r = 0.63, P < 0.01). The mean ischiofemoral space was 22.9.0 ± 7.0 mm (range, 10.3 to 55 mm), and a weak correlation was found between ischiofemoral space and lesser trochanteric version (r = -0.16, P < 0.05). The lesser trochanteric version showed a high variation with a moderate relationship with the femoral neck version. The lesser trochanteric version does not influence the width of the ischiofemoral space.
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Deep gluteal syndrome describes the presence of pain in the buttock caused from non-discogenic and extrapelvic entrapment of the sciatic nerve. Several structures can be involved in sciatic nerve entrapment within the gluteal space. A comprehensive history and physical examination can orientate the specific site where the sciatic nerve is entrapped, as well as several radiological signs that support the suspected diagnosis. Failure to identify the cause of pain in a timely manner can increase pain perception, and affect mental control, patient hope and consequently quality of life. This review presents a comprehensive approach to the patient with deep gluteal syndrome in order to improve the understanding of posterior hip anatomy, nerve kinematics, clinical manifestations, imaging findings, differential diagnosis and treatment considerations.
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There is a continuum of hamstring injuries that can range from musculotendinous strains to avulsion injuries. Although the proximal hamstring complex has a strong bony attachment on the ischial tuberosity, hamstring injuries are common in athletic population and can affect all levels of athletes. Nonoperative treatment is mostly recommended in the setting of low-grade partial tears and insertional tendinosis. However, failure of nonoperative treatment of partial tears may benefit from surgical debridement and repair. The technique presented on this article allows for the endoscopic management of proximal hamstring tears and chronic ischial bursitis, which until now has been managed exclusively with much larger open approaches. The procedure allows for complete exposure of the posterior aspect of the hip in a safe, minimally invasive fashion.
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Deep gluteal syndrome describes the presence of pain in the buttock caused from non-discogenic and extrapelvic entrapment of the sciatic nerve. Several structures can be involved in sciatic nerve entrapment within the gluteal space. A comprehensive history and physical examination can orientate the specific site where the sciatic nerve is entrapped, as well as several radiological signs that support the suspected diagnosis. Failure to identify the cause of pain in a timely manner can increase pain perception, and affect mental control, patient hope and consequently quality of life. This review presents a comprehensive approach to the patient with deep gluteal syndrome in order to improve the understanding of posterior hip anatomy, nerve kinematics, clinical manifestations, imaging findings, differential diagnosis and treatment considerations.
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The concept of psoas impingement secondary to a tight or inflamed iliopsoas tendon causing impingement of the anterior labrum during hip extension has been suggested. The purpose of this study was to assess the relationship between the lesser trochanteric version (LTV) in symptomatic patients with psoas impingement as compared with asymptomatic hips. The femoral neck version (FNV) and LTV were evaluated on axial magnetic resonance imaging, as well as the angle between LTV and FNV. Data from 12 symptomatic patients and 250 asymptomatic patients were analysed. The mean, range and standard deviations were calculated. Independent t-tests were used to determine differences between groups. The lesser trochanteric retroversion was significantly increased in patients with psoas impingement as compared with asymptomatic hips (−31.1° SD ± 6.5 versus −24.2° ± 11.5, P < 0.05). The FNV (9° ± 8.8 versus 14.1° ± 10.7, P > 0.05) and the angle between FNV and LTV (40.2° ± 9.7 versus 38.3° ± 9.6, P > 0.05) were not significantly different between groups. In conclusion, the lesser trochanteric retroversion is significantly increased in patients with psoas impingement as compared with asymptomatic hips.
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Pain in the buttock radiating to the popliteal fossa associated with hamstring weakness can be caused by tethering of the sciatic nerve to the proximal hamstring tendons. Contraction of the hamstring muscles produces traction on the sciatic nerve and subsequent symptoms. Surgical release of the proximal hamstring tendons, in particular from the sciatic nerve, will improve symptoms and function. Case series; Level of evidence, 4. Forty-seven proximal hamstring surgical releases were performed in 44 patients (28 males, 16 females). The initial clinical findings and imaging were obtained from the medical notes, and additional data were obtained from a later questionnaire. The average age at the time of surgery was 29 years (range, 15-58 years). All patients were involved in high-level sports. Long-term follow-up was with a comprehensive postal questionnaire. Full follow-up was obtained in 43 patients (46 operations). Average follow-up was 53 months (range, 9-110). No major complications were encountered from the surgery. The average visual analog scale pain score decreased from 6.5 preoperatively to 2.0 (P < .001). Two patients had increased pain, and pain was unchanged in 4. The average subjective weakness score decreased from 6.6 to 2.8 (P < .001). Three patients reported increased weakness at follow-up, and 3 patients reported that the hamstring muscles felt equally weak. Thirty-four patients (77%) had returned to their previous sporting activities, with 30 patients still competing at or above state level, or professionally, after surgery. The average satisfaction score was 7.8. Six patients (14%) were not satisfied with the outcome of the procedure, 5 patients (11%) were somewhat satisfied, and 33 patients (75%) were very satisfied. Proximal hamstring syndrome occurs mainly in patients participating in competitive sports. Release of the proximal hamstring tendons in this active group resulted in decreased pain and increased strength, and the majority of patients were satisfied with the procedure.
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To investigate the extensibility and stiffness of the hamstrings in patients with nonspecific low back pain (LBP). An experimental design. A university laboratory for human movement analysis in a department of rehabilitation medicine. Forty subjects, a patient group (20) and a healthy control group (20). Subjects laid supine on an examination table with a lift frame, with left leg placed in a sling at the ankle. Straight leg raising, pulling force, and activity of hamstring and back muscles were recorded with electrodes. Patients indicated when they experienced tension or pain. The lift force, leg excursion, pelvic-femoral angle, first sensation of pain, and the electromyogram of the hamstrings and back muscles measured in an experimental straight-leg raising set-up. The patient group showed a significant restriction in range of motion (ROM) and extensibility of the hamstrings compared with the control group. No significant difference in hamstring muscle stiffness can be assessed between both groups. The restricted ROM and the decreased extensibility of the hamstrings in patients with nonspecific LBP is not caused by increased muscle stiffness of the hamstrings, but determined by the stretch tolerance of the patients.
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To validate an operational definition of piriformis syndrome based on prolongation of the H-reflex with hip flexion, adduction, and internal rotation (FAIR) and to assess efficacy of conservative therapy and surgery to relieve symptoms and reduce disability. Before-after trial of cohorts identified by operational definition. Outpatient departments of 2 hospitals and 4 physicians' offices. Surgery performed at 3 hospitals. Consecutive sample of 918 patients (1014 legs) with follow-up on 733. Patients with significant (3 standard deviations [SDs]) FAIR tests received injection, physical therapy, and serially reported pain and disability assessments. Forty-three patients (6.47%) had surgery. Likert pain scale. Subjective estimates of disablement in activities of daily living and instrumental activities of daily living. At 3 SDs, the FAIR test had sensitivity and specificity of.881 and.832, respectively. Seventy-nine percent (514/655) of FAIR test positive (FTP) patients improved 50% or more from injection and physical therapy at a mean follow-up of 10.2 months. Average improvement was 71.1%. Of 385 FTP patients with disability data, mean disability fell from 35.37% prestudy (SD =.2275) to 12.96% poststudy (SD =.1752), a 62.8% improvement. Twenty-eight surgical FTP patients (68.8%) showed 50% or greater improvement; mean improvement was 68% at a mean follow-up of 16 months. Surgery reduced the mean FAIR test to 1.35 +/- 2.17 months postoperatively. FTP patients generally improved 10% to 15% more than others after conservative treatment. The FAIR test correlates well with a working definition of piriformis syndrome and is a better predictor of successful physical therapy and surgery than the working definition. The FAIR test, coupled with injection and physical therapy and/or surgery, appears to be effective means to diagnose and treat piriformis syndrome.
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Several urogynecologic syndromes are associated with the clinical finding of a short, painful, tender and weak pelvic floor and a variety of connective tissue abnormalities. Techniques for rehabilitation include the avoidance of perpetuating factors, rehabilitation of extrapelvic musculoskeletal abnormalities, the use of manual techniques and needling to promote resolution of connective tissue problems, closure of any diastasis recti, and transvaginal/transrectal manual release of muscular trigger points and contractures. Therapy can be facilitated by pudendal or epidural nerve block. Patients contribute to their success through home maintenance programs.
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Hamstring strains are one of the most common muscle strains in athletes; however, complete rupture of the proximal hamstring origin is rare and results from significant trauma. The objective of this paper is to present our experience of management of complete ruptures where surgical repair resulted in good results in both acute and delayed cases. Two water skiers and two bull riders sustained complete rupture of the proximal origin of the hamstring muscles. All underwent repair of the hamstring origin and sciatic nerve neurolysis. A post operative hamstring rehabilitation programme was instituted. Regular follow up was performed at 2, 3, 6, 9, and 12 months. At a minimum final follow up of 12 months all patients had regained functional knee flexion strength with no pain and a near normal range of knee flexion. All four individuals were able to return to their previous line of work and three were able to return to their pre-injury level of sport. Complete rupture of the hamstring origin is a potentially devastating sports injury that has implications affecting the individual's activities of daily living as well as potential as a sportsperson. Surgical repair restores the distorted anatomy, allows early functional rehabilitation, and avoids the potential debilitating neurological problem of gluteal sciatica.
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Purpose: To assess the relationship between the femoral neck version (FNV) and lesser trochanteric version (LTV) in symptomatic patients with ischiofemoral impingement (IFI) as compared with asymptomatic hips. Methods: The FNV and LTV of patients with symptomatic IFI who underwent magnetic resonance imaging assessment including a standardized femoral version study protocol were compared with those of patients with asymptomatic hips in this retrospective, observational study. Patients with isolated intra-articular pathology, prior hip fracture, and lesser trochanter deformity were excluded. The FNV, LTV, ischiofemoral space, and quadratus femoris space were evaluated on axial magnetic resonance imaging, as well as the angle between the LTV and the FNV. Independent t-tests were used to determine differences between groups. Results: Data from 11 out 15 symptomatic patients and 250 out of 320 asymptomatic patients were analyzed. The mean ischiofemoral space (11.9 v 22.9 mm; P < .001; 95% confidence interval [CI], 6.9 to 15.2) and mean quadratus femoris space (7.2 mm v 14.9 mm; P < .001; 95% CI, 5.4 to 8.6) were significantly smaller in symptomatic patients versus asymptomatic patients. There was no difference in mean LTV between groups (-23.6° v -24.2°; P = .8; 95% CI, -7.5 to 6.4), however, the mean FNV (21.7° v 14.1°; P = .02; 95% CI, -14.2 to -1.1) and the angle between the FNV and LTV on average (45.4° v 38.3°; P = .01; 95% CI, -12.9 to -1.3) were higher in symptomatic than in asymptomatic patients, with statistical significance. Conclusions: The femoral mean neck anteversion and the mean angle between the FNV and LTV are significantly higher in patients with symptomatic IFI. The mean LTV is not increased in patients with symptomatic ischiofemoral impingement as compared with those patients with asymptomatic hips. Level of evidence: Level III, diagnostic study.
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Study design: Controlled laboratory cross-sectional study using single-group, within-subject comparisons. Objectives: To determine whether different types of neurodynamic techniques result in differences in longitudinal sciatic nerve excursion. Background: Large differences in nerve biomechanics have been demonstrated for different neurodynamic techniques for the upper limb (median nerve), but recent findings for the sciatic nerve have only revealed small differences in nerve excursion that may not be clinically meaningful. Methods: High-resolution ultrasound imaging was used to quantify longitudinal sciatic nerve movement in the thigh of 15 asymptomatic participants during 6 different mobilization techniques for the sciatic nerve involving the hip and knee. Healthy volunteers were selected to demonstrate normal nerve biomechanics and to eliminate potentially confounding variables associated with dysfunction. Repeated-measures analyses of variance were used to analyze the data. Results: The techniques resulted in markedly different amounts of nerve movement (P<.001). The tensioning technique was associated with the smallest excursion (mean ± SD, 3.2 ± 2.1 mm; P < or = .004). The sliding technique resulted in the largest excursion (mean ± SD, 17.0 ± 5.2 mm; P<.001), which was approximately 5 times larger than that resulting from the tensioning technique and, on average, twice as large as that resulting from individual hip or knee movements. Conclusion: Consistent with current theories and findings for the median nerve, different neurodynamic exercises for the lower limb resulted in markedly different sciatic nerve excursions. Considering the continuity of the nervous system, the movement and position of adjacent joints have a large impact on nerve biomechanics.
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Purpose The purposes of this study were to investigate the clinical and radiographic presentation of patients with ischiofemoral impingement (IFI) and to assess the outcomes of endoscopic treatment with partial resection of the lesser trochanter. Methods Five patients with IFI who underwent endoscopic treatment with partial resection of the lesser trochanter were retrospectively reviewed. The outcomes were assessed at a mean follow-up of 2.3 years (range, 2 to 2.5 years) through the modified Harris Hip Score and a visual analog scale score for pain. Physical examination tests provoking the impingement between the lesser trochanter and ischium were used for the diagnosis of IFI, including the IFI test and reproducible pain lateral to the ischium with the long-stride walking test. The presence of quadratus femoris muscle edema and a decreased ischiofemoral space on magnetic resonance imaging was also necessary for the diagnosis. Results The mean modified Harris Hip Score increased from 51.3 points (range, 34.1 to 73.7 points) preoperatively to 94.2 points (range, 78.1 to 100 points) at the final follow-up (P = .003). The mean visual analog scale score for pain decreased from 6.6 (range, 6 to 7.3) before surgery to 1 (range, 0 to 4) at the final follow-up (P = .001). The mean duration to return to sport after surgery was 4.4 months (range, 1 to 7 months) for the 5 patients in this study. No complication was observed. Conclusions The endoscopic treatment of IFI was effective at 2 years in 5 patients with consistent clinical and imaging diagnostic findings. Level of Evidence Level IV, therapeutic case series.
Article
Purpose: To evaluate continuity of the sacrotuberous ligament (STL) in normal and abnormal hamstring (HS) tendons on magnetic resonance (MR) images and to test the hypothesis that greater degrees of HS retraction are correlated with STL discontinuity. Materials and methods: The institutional review board approved this retrospective HIPAA-compliant study and waived informed consent. Control cohort comprised 33 patients (mean age, 54.1 years) without HS abnormalities at hip MR arthrography. Study cohort comprised 100 patients (mean age, 55.3 years) with HS abnormalities at pelvic or hip MR imaging. Two musculoskeletal radiologists independently assessed STL continuity with the ischium and semimembranosus (SM) and conjoined biceps femoris and semitendinosus (BF-ST) tendons and evaluated these tendons for tendinopathy, partial tear, or rupture. A third musculoskeletal radiologist measured retraction of ruptured tendons. Inter- and intraobserver agreement was calculated with weighted κ or intraclass correlation coefficients. HS abnormalities in the cohorts were compared with Mann-Whitney test. In patients with tendon rupture, relationships between qualitative (STL and HS attachments) and quantitative (tendon retraction measurements) data were analyzed with analysis of variance and linear regression with Bonferroni correction. Results: STL was continuous with ischium in all patients. In control patients, STL was always continuous with BF-ST but never continuous with SM. In study patients, BF-ST tendon alone, SM tendon alone, and both BF-ST and SM tendons showed abnormalities in 17, six, and 77 patients, respectively. HS rupture occurred in 24 patients; it involved BF-ST tendon alone in 13 patients and both BF-ST and SM tendons in 11. STL was continuous with BF-ST tendon in 12 patients and discontinuous in 12 patients. Retraction of BF-ST tendon (mean, 33 mm; range, 5-81 mm) was independently correlated with STL continuity with BF-ST (P = .0001) and SM (P = .0004) tendon rupture. Retraction was significantly greater (P ≤ 0.01) when STL was discontinuous and SM tendon was ruptured. Inter- and intraobserver agreement was very good or excellent in categorization of HS abnormalities and measurement of retraction. Conclusion: STL showed continuity with both ischium and BF-ST tendon but not SM tendon. In HS rupture, tendon retraction was significantly less when STL remained attached to BF-ST tendon.
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Nerve injury during acetabular and pelvic fracture fixation can have devastating consequences for trauma patients already in a compromised situation. This study aims to evaluate the efficacy of multimodality intraoperative neurophysiologic monitoring during acetabular and pelvic fracture fixation in identifying emerging iatrogenic nerve injury. Sixty patients were retrospectively identified after surgical fixation following acetabular or pelvic fracture. Neuromonitoring during surgery was performed using three different modalities, transcranial electric motor evoked potential (tceMEP), somatosensory evoked potential (SSEP), and electromyographic (EMG) monitoring. Each modality was evaluated for sensitivity and specificity of detecting an intraoperative nerve injury. tceMEP monitoring was found to be 100% sensitive and 86% specific at detecting an impending nerve injury. The sensitivity and specificity of SSEP were 75% and 94%, while EMG sensitivity was unacceptably low at 20% although specificity was 93%. Multimodality neuromonitoring of transcranial electric motor and peroneal nerve somatosensory evoked potentials with or without spontaneous EMG monitoring is a safe and effective method for detecting impending nerve injury during acetabular and pelvic surgery.
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The purpose of this study was to determine the diagnostic accuracy of the straight leg raise (SLR), active piriformis, and seated piriformis stretch tests in identifying individuals with sciatic nerve entrapment. Thirty-three individuals (female = 25 and male = 8) with a mean age of 43 years (range 15-64; SD ± 11 years) were included in the study. Twenty-three subjects had endoscopic findings of sciatic nerve entrapment. Ten subjects without entrapment during endoscopic assessment were used as a control group. The results of the SLR, active piriformis, and seated piriformis stretch tests were retrospectively reviewed for each subject and compared between both groups. The accuracy of these tests for the endoscopic finding of sciatic nerve entrapment was determined by calculating the sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and diagnostic odds ratio. The SLR had sensitivity of 0.15, specificity of 0.95, positive likelihood ratio of 3.20, negative likelihood ratio of 0.90, and diagnostic odds ratio of 3.59. The active piriformis test had sensitivity of 0.78, specificity of 0.80, positive likelihood ratio of 3.90, negative likelihood ratio of 0.27, and diagnostic odds ratio of 14.40. The seated piriformis stretch test had sensitivity of 0.52, specificity of 0.90, positive likelihood ratio of 5.22, negative likelihood ratio of 0.53, and diagnostic odds ratio of 9.82. The most accurate findings were obtained when the results of the active piriformis test and seated piriformis stretch test were combined, with sensitivity of 0.91, specificity of 0.80, positive likelihood ratio of 4.57, negative likelihood ratio of 0.11, and diagnostic odds ratio of 42.00. The active piriformis and seated piriformis stretch tests can be used to help identify patients with and without sciatic nerve entrapment in the deep gluteal region. LEVEL OF EVIDENCE: II.
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The history and physical examination of the hip is the key component for evaluation of patients presenting with hip pain. As our understanding of the anatomy and biomechanics of the normal hip vs the pathologic hip advances, the physical examination progresses as well. As with the shoulder and knee examinations, there are critical steps that form the basis of the examination of the hip joint. This hip examination contains 21 steps, which compares well with the shoulder 20 step exam and the knee 33 step exam. Consideration should be given for the hip as comprised of 4 layers: the osseous, capsulolabral, musculotendinous, and neurovascular. The hip represents the link between the upper body and lower body, therefore the fifth layer, the kinematic chain, plays an essential role in treatment recommendations. A clinical evaluation of the hip that incorporates this multifactor thought process will lead to an accurate diagnosis in a timely manner. This paper is a description of the 21 core examinations of a standardized clinical evaluation of the hip.
Article
Hamstring syndrome is a gluteal sciatic pain, in which posttraumatic or congenital fibrotic hard bands irritate sciatic nerve at the insertion site of hamstring muscles to ischial tuberosity. The tendon-like or scarred bands are located deep to the biceps femoris insertion, on its anterolateral or anterior side. They compress the sciatic nerve while sitting and, especially, when hip joint is flexed with knee extended. Cyclic stress causes a permanent local pain at the ischial tuberosity that radiates down the posterior thigh. Hamstring syndrome can be treated surgically by dividing the compressing bands. The operative technique has some modifications and the incision site is individually selected according to the anatomy and structure of the patient. The main lines for operative treatment are given in this report. The results are usually good, but in the postoperative treatment, long, close follow-up of patients as well as modification of the rehabilitation and training has to be done.
Article
Background Low back pain is fairly prevalent among golfers; however, its precise biomechanical mechanism is often debated. Hypothesis There is a positive correlation between decreased lead hip rotation and lumbar range of motion with a prior history of low back pain in professional golfers. Study Design A cross-sectional study. Methods Forty-two consecutive professional male golfers were categorized as group 1 (history of low back pain greater than 2 weeks affecting quality of play within past 1 year) and group 2 (no previous such history). All underwent measurements of hip and lumbar range of motion, FABERE's distance, and finger-to-floor distance. Differences in measurements were analyzed using the Wilcoxon signed rank test. Results 33% of golfers had previously experienced low back pain. A statistically significant correlation (P < .05) was observed between a history of low back pain with decreased lead hip internal rotation, FABERE's distance, and lumbar extension. No statistically significant difference was noted in nonlead hip range of motion or finger-to-floor distance with history of low back pain. Conclusions Range-of-motion deficits in the lead hip rotation and lumbar spine extension correlated with a history of low back pain in golfers.
Article
Objectives: Piriformis Muscle Syndrome (PMS) is caused by sciatic nerve compression in the infrapiriformis canal. However, the pathology is poorly understood and difficult to diagnose. This study aimed to devise a clinical assessment score for PMS diagnosis and to develop a treatment strategy. Material and methods: Two hundred and fifty patients versus 30 control patients with disco-radicular conflict, plus 30 healthy control subjects were enrolled. A range of tests was used to produce a diagnostic score for PMS and an optimum treatment strategy was proposed. Results: A 12-point clinical scoring system was devised and a diagnosis of PMS was considered 'probable' when greater or equal to 8. Sensitivity and specificity of the score were 96.4% and 100%, respectively, while the positive predictive value was 100% and negative predictive value was 86.9%. Combined medication and rehabilitation treatments had a cure rate of 51.2%. Hundred and twenty-two patients (48.8%) were unresponsive to treatment and received OnabotulinumtoxinA. Visual Analogue Scale (VAS) results were 'Very good/Good' in 77%, 'Average' in 7.4% and 'Poor' in 15.6%. Fifteen of 19 patients unresponsive to treatment underwent surgery with 'Very good/Good' results in 12 cases. Conclusions: The proposed evaluation score may facilitate PMS diagnosis and treatment standardisation. Rehabilitation has a major role associated in half of the cases with botulinum toxin injections.
Article
The purpose of this study was to develop a self-administered evaluative tool to measure health-related quality of life in young, active patients with hip disorders. This outcome measure was developed for active patients (aged 18 to 60 years, Tegner activity level ≥ 4) presenting with a variety of symptomatic hip conditions. This multicenter study recruited patients from international hip arthroscopy and arthroplasty surgeon practices. The outcome was created using a process of item generation (51 patients), item reduction (150 patients), and pretesting (31 patients). The questionnaire was tested for test-retest reliability (123 patients); face, content, and construct validity (51 patients); and responsiveness over a 6-month period in post-arthroscopy patients (27 patients). Initially, 146 items were identified. This number was reduced to 60 through item reduction, and the items were categorized into 4 domains: (1) symptoms and functional limitations; (2) sports and recreational physical activities; (3) job-related concerns; and (4) social, emotional, and lifestyle concerns. The items were then formatted using a visual analog scale. Test-retest reliability showed Pearson correlations greater than 0.80 for 33 of the 60 questions. The intraclass correlation statistic was 0.78, and the Cronbach α was .99. Face validity and content validity were ensured during development, and construct validity was shown with a correlation of 0.81 to the Non-Arthritic Hip Score. Responsiveness was shown with a paired t test (P ≤ .01), effect size of 2.0, standardized response mean of 1.7, responsiveness ratio of 6.7, and minimal clinically important difference of 6 points. We have developed a new quality-of-life patient-reported outcome measure, the 33-item International Hip Outcome Tool (iHOT-33). This questionnaire uses a visual analog scale response format designed for computer self-administration by young, active patients with hip pathology. Its development has followed the most rigorous methodology involving a very large number of patients. The iHOT-33 has been shown to be reliable; shows face, content, and construct validity; and is highly responsive to clinical change. In our opinion the iHOT-33 can be used as a primary outcome measure for prospective patient evaluation and randomized clinical trials.
Article
Proximal hamstring injuries occur during eccentric contraction with the hip and the knee on extension; hence they are relatively frequent lesions in specific sports such as water skiing and hurdle jumping. Additionally, the trend toward increasing activity and fitness training in the general population has resulted in similar injuries. Myotendinous strains are more frequent than avulsion injuries. Discrimination between the two types of lesions is relevant for patient management, since the former is treated conservatively and the latter surgically. MRI and Ultrasonography are both well suited techniques for the diagnosis and evaluation of hamstring tendon injuries. Each one has its advantages and disadvantages. The purpose of this article is to provide a comprehensive review of the anatomy and biomechanics of the proximal hamstring muscle-tendon-bone unit and the varied imaging appearances of hamstring injury, which is vital for optimizing patient care. This will enable the musculoskeletal radiologist to contribute accurate and useful information in the treatment of athletes at all levels of participation.
Article
The purpose of this study was to investigate the historical, clinical, and radiographic presentation of deep gluteal syndrome (DGS) patients, describe the endoscopic anatomy associated with DGS, and assess the effectiveness of endoscopic surgical decompression for DGS. Sciatic nerve entrapment was diagnosed in 35 patients (28 women and 7 men). Portals for inspection of the posterior peritrochanteric space (subgluteal space) of the hip were used as well as an auxiliary posterolateral portal. Patients were treated with sciatic nerve decompression by resection of fibrovascular scar bands, piriformis tendon release, obturator internus, or quadratus femoris or by hamstring tendon scarring. Postoperative outcomes were evaluated with the modified Harris Hip Score (MHHS), verbal analog scale (VAS) pain score, and a questionnaire related specifically to sciatic hip pain. The mean patient age was 47 years (range, 20 to 66 years). The mean duration of symptoms was 3.7 years (range, 1 to 23 years). The mean preoperative VAS score was 6.9 ± 2.0, and the mean preoperative MHHS was 54.4 ± 13.1 (range, 25.3 to 79.2). Of the patients, 21 reported preoperative use of narcotics for pain; 2 continued to take narcotics postoperatively (unrelated to initial complaint). The mean time of follow-up was 12 months (range, 6 to 24 months). The mean postoperative MHHS increased to 78.0 and VAS score decreased to 2.4. Eighty-three percent of patients had no postoperative sciatic sit pain (inability to sit for >30 minutes). Endoscopic decompression of the sciatic nerve appears useful in improving function and diminishing hip pain in sciatic nerve entrapment/DGS.
Article
The 21 muscles that cross the hip provide both triplanar movement and stability between the femur and acetabulum. The primary intent of this clinical commentary is to review and discuss the current understanding of the specific actions of the hip muscles. Analysis of their actions is based primarily on the spatial orientation of the muscles relative to the axes of rotation at the hip. The discussion of muscle actions is organized according to the 3 cardinal planes of motion. Actions are considered from both femoral-on-pelvic and pelvic-on-femoral perspectives, with particular attention to the role of coactivation of trunk muscles. Additional attention is paid to the biomechanical variables that alter the effectiveness, force, and torque of a given muscle action. The role of certain muscles in generating compression force at the hip is also presented. Throughout the commentary, the kinesiology of the muscles of the hip are considered primarily from normal but also pathological perspectives, supplemented with several clinically relevant scenarios. This overview should serve as a foundation for understanding the assessment and treatment of musculoskeletal impairments that involve not only the hip, but also the adjacent low back and knee regions.
Article
Pudendal neuralgia is a painful, neuropathic condition involving the dermatome of the pudendal nerve. This condition is not widely known and often unrecognized by many practitioners. The International Pudendal Neuropathy Association (tipna.org) estimates the incidence of this condition to be 1/100,000; however, most practitioners treating patients with this condition feel the actual rate of incidence may be significantly higher. Currently, there is fair paucity of medical literature and scientific evidence in the diagnosis and treatment of pudendal neuralgia. Diagnosis of this condition is based on the utilization of Nantes Criteria, in conjunction with clinical history and physical findings. CT-scan guided nerve blocks are also employed, by this author, to provide additional information. Subsequent treatment of pudendal neuralgia is medical and well as surgical, with Physical Therapy a key component to all aspects of treatment. The goal of this paper is to present evidence based information, as well as personal clinical experience, in treating approximately 200 patients with pudendal neuralgia.
Article
The purpose of this study was to describe the MRI findings of an entity in which patients present with hip pain, abnormal MR signal intensity of the quadratus femoris muscle, and narrowing of the ischiofemoral space. We reviewed MR images of 12 hips in nine patients with hip pain and abnormal MR signal intensity of the quadratus femoris muscle. Using axial MR images, two musculoskeletal radiologists measured the ischiofemoral and quadratus femoris spaces. We also examined changes to muscles and tendons for the presence of edema and tears. Data were compared with 11 hips in 10 control subjects. Statistical analyses determined interobserver variability and differences between groups. Subjects with an abnormal quadratus femoris muscle were all women 30-71 years old (mean age, 53 years) and had significantly narrower ischiofemoral spaces when compared with control subjects (13 +/- 5 vs 23 +/- 8 mm, respectively; p = 0.002). The quadratus femoris space was significantly narrower in affected subjects (7 +/- 3 vs 12 +/- 4 mm; p = 0.002). Abnormalities of the quadratus femoris muscle included edema (100%), partial tear (33%), and fatty infiltration (8%). The hamstring tendons of affected subjects showed evidence of edema (50%) and partial tears (25%). Ischiofemoral impingement may represent a cause of hip pain and should be considered in cases with MR signal abnormality of quadratus femoris muscle.
Article
Complete proximal avulsions of the hamstring muscle group may cause significant morbidity and loss of function. These pelvis-near musculoskeletal injuries are mostly acquired during sports activities in a hip flexion and knee extension. Here we present a study group of 6 middle-aged to elderly patients suffering a complete proximal hamstring avulsion and following early surgical refixation. Early surgical refixation leads to complete resumption of the activities of daily life without loss of function. The 6 patients (3 men and 3 women) included in this study had an average age of 59.07 +/- 4.47 years at the time of injury. All of them suffered a complete avulsion of the hamstring muscle group. Surgical refixation was accomplished with the corkscrew anchor refixation system (Arthrex Manufacturing, Inc., Naples, FL). The cases were retrospectively analyzed using a hip joint evaluation system, the Harris Hip Score, and radiological follow-up by magnetic resonance imaging (MRI). Data are given as mean +/- SEM. Student's t-test was used for normal distribution of the data. The mean follow-up time was 31.83 +/- 18.9 months (range: 10-118 months). All patients were rated not to have a significant difference in function compared with the uninjured side. None of the patients suffered any handicaps resulting from surgery or the injury. A complete consolidation in all patients was observed in the follow-up MRI. Early surgical intervention and subsequent therapy in a complete hamstring avulsion injury may prevent loss of hip-joint stability and prevent the sequelae of degradative hip or vertebral events.
Article
This study compared proximal femoral bone resorption in hybrid total hip arthroplasty cases that had poor or good contact between the collar and proximal medial femoral neck. A total of 94 patients (102 hips) comprised the study group. Mean patient age was 52 years, and mean follow-up was 4.86 years. Bone resorption of the proximal femur was evaluated with immediate postoperative and follow-up anteroposterior and lateral radiographs. Statistical analysis using the Mann-Whitney test showed no significant difference between the groups that had good or poor contact. The collar did not prevent calcar resorption even when ideal contact was achieved.
Article
To examine whether passive hip rotation motion was different between people with and without low back pain (LBP) who regularly participate in sports that require repeated rotation of the trunk and hips. We hypothesized that people with LBP would have less total hip rotation motion and more asymmetry of motion between sides than people without LBP. Two group, case-control. University-based musculoskeletal analysis laboratory. Forty-eight subjects (35 males, 13 females; mean age: 26.56+/-7.44 years) who reported regular participation in a rotation-related sport participated. Two groups were compared; people with LBP (N=24) and people without LBP (N=24; NoLBP). Data were collected on participant-related, LBP-related, sport-related and activity-related variables. Measures of passive hip rotation range of motion were obtained. The differences between the LBP and NoLBP groups were examined. People with and without a history of LBP were the same with regard to all participant-related, sport-related and activity-related variables. The LBP group had significantly less total rotation (P=.035) and more asymmetry of total rotation, right hip versus left hip, (P=.022) than the NoLBP group. Left total hip rotation was more limited than right total hip rotation in the LBP group (P=.004). There were no significant differences in left and right total hip rotation for the NoLBP group (P=.323). Among people who participate in rotation-related sports, those with LBP had less overall passive hip rotation motion and more asymmetry of rotation between sides than people without LBP. These findings suggest that the specific directional demands imposed on the hip and trunk during regularly performed activities may be an important consideration in deciding which impairments may be most relevant to test and to consider in prevention and intervention strategies.
Article
The bony anatomy of the hip leads to a limited array of impingement syndromes, more frequently resulting from abnormal contact between the femoral neck and acetabulum. We report an unusual case of osseous impingement between the lesser trochanter and ischium, with involvement of the intervening quadratus femoris muscle. While the prevalence and etiology of this finding is unclear, it may represent a cause for hip pain.
Article
Pain that persist in a hip after an otherwise successful replacement arthroplasty may be due to a pinching of soft tissues between bone prominences. In this report, two patients are described who had painful impingement between the lesser trochanter and the ischial ramus and who were relieved of their pain by excision of the lesser trochanter. A third patient is discussed to illustrate how this problem can be anticipated and avoided at the time of total hip arthroplasty. During total hip arthroplasty, a tendency toward impingement may be recognized by palpating the two structures once the prosthesis is in place and the hip is extended, adducted, and externally rotated. Care with certain operative details, such as using a femoral prosthesis with a long neck and a neck-stem angle small enough to allow the lesser trochanter to clear the pelvis, also helps avoid the complications. When there is distortion of the involved bones, it may be important to resect any bone protuberances in the proximal femoral and periacetabular regions.
Article
Hamstring muscle strain represents a significant injury to the athlete participating in sporting activities. Lack of hamstring flexibility has been correlated to hamstring muscle injury. There is, however, conflict concerning the most efficient hamstring stretching technique. The purpose of this study was to compare static stretch (SS) and proprioceptive neuromuscular facilitation (PNF) hamstring stretching techniques while maintaining the pelvis in two testing positions: anterior pelvic tilt (APT) or posterior pelvic tilt (PPT). Two groups of 10 subjects were randomly assigned to either an APT or PPT position. Each subject then performed eight sessions using PNF on one leg and SS on the other leg while maintaining the pelvis in the assigned position. Hamstring flexibility was assessed with the hip positioned at 90 degrees while actively extending the knee, i.e., active knee extension test (AKET). A two-way ANOVA comparing stretching technique and pelvic position revealed that the APT group significantly increased hamstring flexibility (P = 0.0375). There was not a significant difference between SS or PNF stretching technique in the APT position. There was not a significant increase in hamstring flexibility in the PPT group with either stretching technique (P > 0.05). The results suggest that APT position was more important than stretching method for increasing hamstring muscle flexibility.
Article
We developed an animal model of stretch injury to nerve in order to study in vivo conduction changes as a function of nerve strain. In 24 rabbits, the tibial nerve was exposed and stretched by 0%, 6% or 12% of its length. The strain was maintained for one hour. Nerve conduction was monitored during the period of stretch and for a one-hour recovery period. At 6% strain, the amplitude of the action potential had decreased by 70% at one hour and returned to normal during the recovery period. At 12% strain, conduction was completely blocked by one hour, and showed minimal recovery. These findings have clinical implications in nerve repair, limb trauma, and limb lengthening.
Article
The purpose of this study was to characterize and classify the prevalence of passive hip rotation range-of-motion (ROM) asymmetry in healthy subjects (n = 100) and in patients with low back dysfunction (n = 50). We categorized the subjects of both groups as having one of three patterns of hip rotation. Pattern IA existed when all ROM measurements were equal (within 10 degrees). Pattern IB existed when total medial and lateral rotation were equal, but one or more of the individual measurements were unequal. Pattern II existed when total medial rotation ROM was greater than total lateral rotation ROM. Those subjects with total lateral rotation ROM greater than total medial rotation ROM demonstrated pattern III. The distribution of subjects among the ROM pattern categories was significantly different in the patient and healthy subject groups. The frequency of occurrence of pattern III was greater in the patient group than in the healthy subject group. These results suggest an association between hip rotation ROM imbalance and the presence of low back pain.
Article
The effectiveness of intraoperative sciatic nerve monitoring was evaluated for 88 consecutive patients undergoing open reduction and internal fixation for acetabular fractures. Intervention outcomes and pre and postoperative electrophysiologic status were compared to postoperative functional findings. Only 2% of the patients demonstrated iatrogenic sciatic nerve palsies. Functional and evoked potential findings were in agreement for 89% of the patients with postoperative palsies, while 26% of the functionally normal patients showed abnormal evoked potentials. Intervention occurred in 55 surgeries; 80% of interventions involved the peroneal nerve. Forty one of the 55 patients who had interventions based on evoked potential results showed recovery of responses to baseline. Of the 14 patients with incomplete intervention recovery, 11 showed impaired postoperative responses. Patients with preoperative evoked potential abnormalities did not show increased susceptibility to iatrogenic evoked potential changes.
Article
Forty-one consecutive patients requiring surgery for pelvic or acetabular fractures were reviewed to compare the 20 patients (20 fractures) who had SSEP monitoring to the twenty-one patients (22 fractures) in whom monitoring was not available. In the unmonitored group, five patients had a preoperative neurologic deficit (three major/two minor), whereas in the monitored group there were nine patients with deficits (two major/seven minor). Intraoperatively, significant somatosensory evoked potential (SSEP) changes occurred in six of the monitored patients. In five patients the changes resolved on correction of the offending action and there was no postoperative deficit. In the remaining case, SSEP changes did not resolve and the patient awoke with a peroneal palsy. This one monitored patient with a new deficit compares with five patients with postoperative new deficits (or deteriorations) in the unmonitored group. The majority of intraoperative SSEP changes and iatrogenic deficits occurred during surgery through the ilioinguinal approach. During follow-up, the great majority of deficits resolved completely or had significant improvement.
Article
A cross-sectional study was used to determine whether limited range of motion in the hip was present in 100 patients--one group with unspecified low back pain and another group with signs suggesting sacroiliac joint dysfunction. To determine whether a characteristic pattern of range of motion in the hip is related to low back pain in patients and to determine whether such a pattern is associated with and without signs of sacroiliac joint dysfunction. The sacroiliac joint is often considered a potential site of low back pain. Problems with the sacroiliac joint, as well as with the low back, have often been related to reduced or asymmetric range of motion in the hip. The correlation between sacroiliac joint dysfunction and hip range of motion, however, has not been thoroughly evaluated with reliable tests in a population of patients with low back pain. Passive hip internal and external rotation goniometric measurements were taken by a blinded examiner, while a separate examiner evaluated the patient for signs of sacroiliac joint dysfunction. Patients with sacroiliac joint dysfunction were further classified as having a left or a right posteriorly tilted innominate. The patients with low back pain but without evidence of sacroiliac joint dysfunction had significantly greater external hip rotation than internal rotation bilaterally, whereas those with evidence of sacroiliac joint dysfunction had significantly more external hip rotation than internal rotation unilaterally, specifically on the side of the posterior innominate. Clinicians should consider evaluating for unilateral asymmetry in range of motion in the hip in patients with low back pain. The presence of such asymmetry in patients with low back pain may help identify those with sacroiliac joint dysfunction.
Article
Low back pain is fairly prevalent among golfers; however, its precise biomechanical mechanism is often debated. There is a positive correlation between decreased lead hip rotation and lumbar range of motion with a prior history of low back pain in professional golfers. A cross-sectional study. Forty-two consecutive professional male golfers were categorized as group 1 (history of low back pain greater than 2 weeks affecting quality of play within past 1 year) and group 2 (no previous such history). All underwent measurements of hip and lumbar range of motion, FABERE's distance, and finger-to-floor distance. Differences in measurements were analyzed using the Wilcoxon signed rank test. 33% of golfers had previously experienced low back pain. A statistically significant correlation (P <.05) was observed between a history of low back pain with decreased lead hip internal rotation, FABERE's distance, and lumbar extension. No statistically significant difference was noted in nonlead hip range of motion or finger-to-floor distance with history of low back pain. Range-of-motion deficits in the lead hip rotation and lumbar spine extension correlated with a history of low back pain in golfers.
Article
This study investigated the biomechanics of the sciatic nerve with hind limb positioning in live and euthanized Sprague-Dawley rats after traumatic nerve injury. With radiographic analysis, sciatic nerve excursion and strain were measured in situ during a modified straight leg raise, which included sequential hip flexion and ankle dorsiflexion. Comparisons were made between nerves in uninjured, sham-injured and mild crush-injured rats at the 7-day and 21-day recovery times. Significant strain and proximal excursion of the sciatic nerve were observed in all groups during hip flexion, and additional increased strain was noted during dorsiflexion. Seven days after nerve injury, strain increased significantly during hip flexion (17.64+/-14.12%; p=0.0091) and dorsiflexion (22.56+/-15.47%; p=0.0082) compared to the sham-injured controls. At 21 days after injury, the strains were similar between the injured and sham-injured groups. Nerve bed elongation during straight leg raise causes sciatic nerve strain and excursion towards the moving joint with the greatest movement nearest the moving joint. In the first week after injury, the maximal strain exceeded the level previously shown to impair nerve conduction and circulation.
Article
A modified straight leg raising (SLR) in which ankle dorsiflexion is performed before hip flexion has been suggested to diagnose distal neuropathies such as tarsal tunnel syndrome. This study evaluates the clinical hypothesis that strain in the nerves around the ankle and foot caused by ankle dorsiflexion can be further increased with hip flexion. Linear displacement transducers were inserted into the sciatic, tibial, and plantar nerves and plantar fascia of eight embalmed cadavers to measure strain during the modified SLR. Nerve excursion was measured with a digital calliper. Ankle dorsiflexion resulted in a significant strain and distal excursion of the tibial nerve. With the ankle in dorsiflexion, the proximal excursion and tension increase in the sciatic nerve associated with hip flexion were transmitted distally along the nerve from the hip to beyond the ankle. As hip flexion had an impact on the nerves around the ankle and foot but not on the plantar fascia, the modified SLR may be a useful test to differentially diagnose plantar heel pain. Although the modified SLR caused the greatest increase in nerve strain nearest the moving joint, mechanical forces acting on peripheral nerves are transmitted well beyond the moving joint.
Article
Avulsion of the proximal origin of the hamstrings has become a more frequently recognized athletic injury. Most orthopaedic surgeons rarely operate in this anatomic area. The purpose of the present study was to define the anatomy of the proximal origin of the hamstrings and its relationship to neurovascular and muscular structures encountered during a repair of a complete avulsion. Fourteen fresh-frozen hip-to-foot human cadaveric specimens were dissected in the prone position. The proximal origin of the hamstrings and its relationship to the surrounding neurologic and muscular structures were documented and measured with use of digital calipers. Six of the fourteen specimens were from female donors. The average age of the donors at the time of death was 68 +/- 13 years. The average height of the donors was 66 +/- 3.5 in (167 +/- 8.9 cm), and the average weight was 142 +/- 39 lb (64 +/- 17.7 kg). The semitendinosus and biceps femoris have a common tendinous site of origin on the ischium. A number of measurements were obtained. The musculotendinous junctions of the semitendinosus and biceps femoris separated at an average of 9.9 +/- 1.5 cm from the most proximal origin site on the ischium. The average distance from the proximal border of the semitendinosus/biceps femoris origin to the inferior border of the gluteus maximus was 6.3 +/- 1.3 cm. At the lateral border of the ischium, the average distance from the inferior gluteal nerve and artery to the inferior border of the gluteus maximus was 5.0 +/- 0.8 cm. The sciatic nerve was an average of 1.2 +/- 0.2 cm from the most lateral aspect of the ischial tuberosity. The site of origin of the semitendinosus/biceps femoris was oval, with average measurements of 2.7 +/- 0.5 cm from proximal to distal and of 1.8 +/- 0.2 cm from medial to lateral. The site of origin of the semimembranosus was crescent-shaped, with average measurements of 3.1 +/- 0.3 cm from proximal to distal and of 1.1 +/- 0.5 cm from medial to lateral. The semitendinosus and biceps femoris have a common tendon of origin on the ischium, and the semimembranosus originates just laterally. The proximal origin of the hamstrings has intimate relationships with the inferior gluteal nerve and artery and the sciatic nerve, which may be at risk during surgical dissection and retraction.
Article
To examine whether lumbopelvic motion associated with a clinical test of active hip lateral rotation (HLR) systematically varied between people classified into 1 of 2 low back pain (LBP) subgroups: lumbar rotation (Rot) or lumbar rotation with extension (RotExt); and, specifically, to determine whether the timing of hip and lumbopelvic rotation with HLR would be more symmetric, right versus left, in people in the Rot subgroup compared with the RotExt subgroup. Two-group, cross-sectional. A university-based movement science laboratory. Subjects were 39 people (23 men, 16 women; mean age, 28.1+/-8.0 y) with chronic or recurrent LBP who regularly participated in a rotation-related sport and associated their LBP symptoms with participation. Not applicable. Subjects participated in a standardized clinical examination to classify their LBP problem. A 3-dimensional movement system was used to capture kinematics of hip and lumbopelvic rotation during the test of active HLR. To examine timing of motion between the hip and lumbopelvic region, the difference in time between the start of hip and lumbopelvic rotation was calculated (startdiff). Symmetry of motion was indexed by the correlation (r) between right and left startdiff and the coefficient of determination (r2) for each LBP subgroup. There were no significant differences between the 2 groups with regard to subject, LBP, activity, and range of motion variables (P range, >.05 for all comparisons). People in the Rot subgroup displayed significantly more symmetry of timing of hip and lumbopelvic rotation motion with active HLR than people in the RotExt subgroup (Rot subgroup: r=.94, r2=.88, P=.00; RotExt subgroup: r=.31, r2=.10, P=.12). People in the Rot and RotExt subgroups displayed systematic differences in how they moved the hip and lumbopelvic region with the clinical test of active HLR. These findings are potentially important because such differences in movement patterns between subgroups of people with LBP suggest different contributing factors and may require different treatments to affect the movement patterns.