Neuromuscular disorders of the hip joint and pelvis

Question 1

Why is activity-related groin pain so common in some sports?

Answer 1

-complex anatomy
-high load
high velocity
-poor rehab of past injuries

Question 2

What is so special about the adductor region?

Answer 2

the blending of muscle fibres - no single attachment point for each muscle

Question 3

Why is the femur curved in the saggital plane?

Answer 3

it means that the adductors can function as extensors or flexors

Question 4

Where is adductor longus at the highest risk of strain injury?

Answer 4

during transition from hip extension to hip flexion

Question 5

What is the definition of a diagnosis?

Answer 5

pathoanatomical source of symtoms

• type of pathology
• where, what, when

Question 6

What is the classification?

Answer 6

the ‘why’ of the disorder, and why it developed

Question 7

According to the Doha agreement, what are the terminologies for groin pain?

Answer 7

-adductor-related
-iliopsoas-related
-pubic-related
-inguinal-related
They are all interconnected

Question 8

Adductor-related groin pain

Answer 8

• adductor tendonopathy/enthesopathy

- adductor tenderness and pain on resisted adduction testing

Question 9

Ilio-psoas related groin pain

Answer 9

• iliopsoas tendinopathy or bursitis

- pain on resisted hip flexion and/or pain on stretching hip flexors

Question 10

Inguinal-related groin pain

Answer 10

• abdominal conjoined tendinopathy
• enthesis on inguinal ligament
• pain at inguinal canal region and tenderness of inguinal canal (but no palpable hernia)
• pain on cough, sneeze, valsalva

Question 11

Pubic-related groin pain

Answer 11

• BSI (osteitis pubis), stress # pubic rami/body of pubis

- tenderness of pubic synthesis and immediately adjacent bone

Question 12

Subjective examination features of inguinal-related groin pain

Answer 12

Symptom behaviour:
-uni/bi-lateral prox groin pain with running, kicking, change of direction 
-cough/sneeze provocative 
Activity 
-loss of acceleration/speed
-loss of kick distance
PRO
-HAGOS
HPC
-insidious onset or acute event preceding persisting symptoms 
-chronic + episodic  
Loading history
-change of position
change/fluctuation in training/loading

Question 13

Physical examination features of inguinal-related groin pain

Answer 13

Diagnostic tests

• pain on resisted trunk flexion/adductor resistance
• lower abdominal wall TOP
• Copenhagen 5 sec squeeze test
• rule out other MSK conditions FABER, FADIR, obturator nerve examination

Question 14

Subjective examination features of pubic-related groin pain

Answer 14

Symptom behaviour
-uni/bi-lateral proximal groin pain with running, kicking, changing direction 
-post activity/morning stiffness 
Activity
-loss of acceleration/speed
-loss of kick distance
PRO
-HAGOS
HPC
-insidious onset or acute event preceding persisting symptoms 
-chronic + episodic  
-limited/no improvement with rest in ST
Loading history
-change of position
change/fluctuation in training/loading

Question 15

Physical examination features of pubic-related groin pain

Answer 15

Diagnostic tests

• pain on resisted adductor resistance
• pubic bone TOP
• Copenhagen 5 sec squeeze test
• rule out other MSK conditions FABER, FADIR, obturator nerve examinatio

Question 16

Subjective examination features of adductor-related groin pain

Answer 16

Symptom behaviour
-uni/bi-lateral prox groin pain with running, kicking, change of direction
-post activity/morning stiffness 
Activity
-loss of acceleration/speed
-loss of distance with long kicks
-stiffness/tighness during/after activity
PRO
-HAGOS
HPC
- insidious onnset or may have acute event  preceding persisting symptoms 
Loading history
-change of position
-change in training

Question 17

Physical examination features of adductor-related groin pain

Answer 17

Diagnostic

• pain on resisted adductor resistance
• adductor TOP
• Copenhagen 5 sec squeeze

Question 18

Clinical features of hip joint arthropathy

Answer 18

Symptom behaviour
-pain with loading/WB
-stiffness/pain after rest
-hip joint stiffness.loss of mobility/mechanical symptoms 
PROs
-HOS
-oxford hip score
-Harris hip score
-WOMAC
HPC
-insidious onsent
history of past hip trauma

Question 19

Hip OA objective clinical features

Answer 19

Tests
-FADIR
-quadrant
-FABER
Observation
-hip in open-pack position 
Hip ROM
-impingement signs at EROM
-equal loss of AROM and PROM
-ROM loss in capsular pattern

Question 20

What are dynamic factors affecting the hip joint?

Answer 20

• abnormal stress and contact between femoral head and acetabular rim
• but motion stresses are normal
• mechanical stresses can result in reactive hip pain

Question 21

What is FAI?

Answer 21

• abnormal contact between femoral head and acetabular leading to compression/impingement +/- tearing of acetabular labrum
• likely to occur during twisting or pivoting that require a relatively large hip ROM
• variation of bony morphology

Question 22

What are the two principal forms of FAI?

Answer 22

• pincer: caused by excessive acetabular cover

- cam: caused by non-spherical head and resultant loss of femoral head-neck offset

Question 23

What is the mechanism of a cam deformity development?

Answer 23

• reactive bone apposition at antero-superior aspect of head neck junction
• sports activity that alter shape of growth plate