sports hip Flashcards
Athletic Pubalgia/sports hernia
what is it? what’s injured? association?
Tenderness to palpation over the pubic tubercle, lower rectus abdominis, or adductor tendons, Pain with resisted sit-up and leg adduction. Pain in these areas may be exacerbated by resisted sit-up with the hips extended and the ipsilateral hip crossed over in a figure-of-4 position or by the external rotation Stinchfield test.
- Groin pain, inguinal regiona w/o overt hernia.
- imbalance of muscle forces across the pubis
- Pathologies include: rectus abdominus insertion tearing or abnormalities; tearing or **attenuation of the transversalis fascia or conjoint tendon; partial avulsion of the internal oblique muscle fibers** at their insertion on the pubic tubercle; tearing of the internal or external oblique musculature or aponeurosis; weakening of the inguinal ring; and tendinitis or partial tearing of the adductor muscle group at its origin, commonly the adductor longus
- risk of surgery: Nerve dysesthesia occurs in less than 1% of patients and most commonly involves the anterior/lateral femoral cutaneous nerve, ilioinguinal nerve, and genitofemoral nerve distributions
FAI association: 50% of athletes with groin pain syndrome are thought to have a labral tear, and 86% of athletes with groin pain syndrome have FAI observed on radiographs. If the physician believes that both pathologies are considerable contributors to pain, then both pathologies should be managed surgically because addressing only one pathology likely will result in an inferior outcome. In a study of patients with FAI and athletic pubalgia, the patients who underwent groin surgery alone returned to their previous level of sports activity 25% of the time. The patients who underwent hip arthroscopy for the management of FAI alone returned to their previous level of sports activity 50% of the time. The patients who underwent combined surgical treatment returned to their previous level of sports activity 85% to 91% of the time.
groin pull
groin pull mechanism, and mgmt
- forceful external rotation of an abducted leg
- rest, ice, and protected weight bearing, followed by a rehabilitation program that begins with gentle stretching and progresses to resistance exercise with a gradual return to sports.
- Immobilization should be avoided because this promotes muscle tightness and scarring
MRI: severe avulsion injury of the adductor muscle from the pubic ramus with muscle edema and hemorrhage
Athletic Pubalgia/groin pain
Adductor related groin pain in athlete: Normal MRI next step? Enthesopathy on MRI?
corticosteroid injection into the pubic cleft can be expected to provide at least 1 year of relief of adductor-related groin pain in a competitive athlete with normal findings on MRI
No injection if enthesopathy on MRI, when there is evidence of enthesopathy on MRI in this competitive-athlete population, these injections are not therapeutic and are associated with a high likelihood of recurrence of symptoms.
Athletic Pubalgia/groin pain
if stem says lower abdominal pain on exertion. He has pain with resisted hip adduction and with sit-ups. There is no palpable inguinal hernia with a Valsalva maneuver. Failure of non op mgmt should get?
MRI scans are not very helpful in making a diagnosis.
In high-performance athletes who have failed to respond to nonsurgical management, surgical intervention is needed to strengthen the anterior pelvic floor.
osteoitits pubis vs sports hernia
- Appropriate management of osteitis pubis includes rest, nonsteroidal anti-inflammatory drugs, directed rehabilitation, and gradual return to sports.
- Examination with tenderness over the symphysis pubis and pain with resisted rectus abdominus testing is consistent with osteitis pubis as opposed to a sports hernia, where a patient would be tender in the abdomen, not the pubis.
Groin pain syndrome/ sports hernia
An imbalance of what muscles is thought to predispose athletes to groin pain syndrome?
Radiographic evidence of femoroacetabular impingement exists in up to what percentage of patients with groin pain syndrome?
What is a significant risk factor for an athlete to develop groin pain syndrome?
What if a athlete has findings of a labral tear/cam deformity and groinpain/sports hernia symptoms?
Groin pain syndrome is pain in the inguinal region, typically in an athlete, without an overt hernia.
- The Rectus abdominis and adductor longus both act on the pubis in opposing fashion. These strong muscles can cause undue strain on the pubis and inguinal region, leading to chronic tendinitis, fascial tears, symphyseal instability, and other causes of groin pain syndrome.
- Up to 86% of patients with groin pain syndrome have radiographic signs of FAI. The two pathologies often co-exist, which highlights their believed relationship and importance of fully investigating both entities. A careful exam needs to be performed to tease out the true underlying etiology of the patient’s symptoms
- Femoroacetabular impingement: The decreased hip motion and pain can cause an alteration in mechanics and vector of pull on the inguinal region, leading to chronic groin pain
- u/s -guided diagnostic intra-articular or inguinal injection would help delineate how much pain is coming from each pathology. Partial but incomplete relief would point to co-existent pathology and the need for surgical intervention for both intra-articular and extra-articular pathology. MRI might not include adequate sequences to detect inguinal pathology
Groin pain syndrome/sports hernia
MRI with dedicated athletic pubalgia protocol:
whats the most common finding?
How does osteitis pubis show up?
- dedicated athletic pubalgia protocol should be used, which includes a
large and small field-of-view sequence focused on the pubic symphysis. - most common finding: fluid signal extending from the anterior-inferior rectus abdominis insertion to the adductor tendons origin on sagittal or axial MRIs.
- ** Osteitis pubis is indicated by symmetric bone marrow edema of the pubic bones or fluid in the symphysis and surrounding soft tissues. **
- MRI is associated with a sensitivity and specificity as high as 68% and 100%, respectively, for the detection of rectus abdominis tendinopathy, and a sensitivity and specificity as high as 86% and 89%, respectively, for the detection of adductor longus tendinopathy. MRI also aids in detecting inguinal or femoral hernias
MRI of the hip and pelvis of a 22-year-old football player with left-sided lower abdominal and proximal adductor-related pain shows disruption of the distal rectus abdominis/adductor aponeurosis on the left (arrow)
Gluteus med/min injury:
Most common in what demongraphic?
3 common clinical scenarios?
tx?
- Abductor tendon tears are more common in females (wider pelvis). They have been shown to have a peak incidence between 50 and 70 years of age, with the prevalence of tears being 25% for women and 10% for men in this age range
- Weakness or trendelenburg gait. Get an MRI.
- chronic, atraumtic tear of anterior fibers
- arthroplastic after femoral neck fx, 22% hvae tear anterior 1/3rd
- THA, found in 20% or injuried during the anterolateral or trnasgluteal approach
- CSI vs PRP (prp has better sustained outcomes at 2 years vs CSI)
- Good outcomes, similiar outcomes open vs endoscopic. High grade fatty infiltration associated with less improvement.
- A high success rate is associated with gluteus maximus transfer for abductor deficiency.
Both muscles receive blood supply from the superior gluteal artery and are innervated by the superior gluteal nerve (L4, L5, S1).
Trendelenburg gait vs caxalgic gait
Trendelnburg gaits results from weakness of? which is innervated by what nerve root?
In patients with a Trendelenburg gait, which of the following gait patterns is exhibited?
- Trendelenburg gait results from a defective hip abductor mechanism that causes the drooping of the pelvis on the contralateral side of the injured hip. A Trendelenburg test can be performed with the physician standing behind the patient and observing if the patient’s contralateral pelvis drops as he or she lifts the injured lower extremity
* gluteus medius, L5 - pelvis on the swing phase of gait drops, and this leads to increased adduction of the affected hip during the stance phase. Patients with weakened hip abductors should hold a cane in their contralateral hand to assist with support of the pelvis during this phase of gait. In the absence of a cane, patients will often lean their torso toward the affected side. This shifts the center of gravity closer to the affected hip, decreasing the moment arm force required by the hip abductors.
Illustration shows the Trendelenburg gait. The Trendelenburg gait is very similar in appearance to a coxalgic gait, with one main distinguishing feature: the tilt of the pelvis. In the Trendelenburg gait (A), the contralateral hemipelvis drops during the single-limb stance phase on the affected side because of severe abductor insufficiency. In the coxalgic gait (B), the pelvis remains level. (Adapted with permission from Hoppenfeld S: Physical Examination of the Spine and Extremities. Upper Saddle, NJ, Pearson Education, 1976, p 164.)
hip lag sign test
- positive test finding is substantially correlated with hip abductor injuries
- The top knee is flexed 45°; the physician passively moves the hip into 10° of extension, 20° of abduction, and maximal internal rotation and instructs the patient to hold this position. If the foot drops more than 10 cm, then the test finding is positive
Hamstring injuries
Proximal hamstring injuries most often occur with the ?
This differs from intramuscular or musculotendinous injuries, which often occur during ???
Risk factors
indications for non op:
Coronal (A) and axial (B) MRIs of a pelvis show a left full-thickness, proximal hamstring tear with retraction and edema/hematoma (arrows).
- hip flexed and the knee extended.The hamstring muscle fibers elongate during the eccentric contraction at the end of the swing phase.
- Take off
- Risk factors: Inadequate preparation refers to deconditioning, inadequate warmup, fatigue, dehydration, or a combination. Muscular dysfunction or imbalance includes hamstring-quadriceps imbalance, hamstring strength deficits, core muscle weakness, and muscular recruitment issues. Anatomic abnormalities include leg-length inequality, short fascicle length, and previous injury. Previous injury is the greatest risk factor for future injury because of scar tissue formation.
- non op: All single tendon tears
Two tendon tears with less than 2 cm retraction39,48
Rupture at the myotendinous junction
Less active patients or those with medical comorbidities that are contraindications to surgical treatment.
Sagittal T2-weightd pelvic MRI shows a right partial avulsion of the proximal hamstring origin with the sickle sign (arrow).
A 68-year-old patient underwent a direct lateral total hip arthroplasty (THA) and now has a Trendelenburg gait. Which nerve most likely is dysfunctional?
The gluteus medius and minimus both are innervated by the superior gluteal nerve. Damage to this nerve during THA may lead to a Trendelenburg gait. The inferior gluteal nerve innervates the gluteus maximus.
