Common Hip

And Pelvic

Injuries in

Sports Medicine DAVID BUCK, MD, CAQ SM

NOVEMBER 13, 2015

Objectives

Review diagnosis of common hip and

pelvic injuries.

Review treatment of common hip and

pelvic injuries.

Review appropriate diagnostic tests for hip

and pelvic injuries.

Review return to play issues for common

hip and pelvic injuries.

Which muscle is not associated

with the correct Apophyses?

A) Sartorius – Anterior Superior Iliac Spine (ASIS)

B) Transversus abdominus and Gluteal muscles –

Iliac Crest

C) Rectus Femoris – Anterior Inferior Iliac Spine

(AIIS)

D) Adductor and Gracilis – Inferior pubic rami

E) Iliopsoas – Greater Trochanter

Apophysis

Definition

Natural protuberance from a bone for

the attachment of muscles

Bony process with an independent

center of ossification and growth plate

which serves as an attachment for a

ligament or tendon

Hip Apophyses: Locations

Iliac Crest – Transversus Abdominus/Glutes

Ischial Tuberosity – Hamstring muscles

Anterior Superior Iliac Spine (ASIS) - Sartorius

Anterior Inferior Iliac Spine (AIIS) – Rectus Femoris

Lesser Trochanter - Iliopsoas

Greater Trochanter – Gluteus medius and

minimus

Inferior pubic rami – Adductor and Gracilis

Hip Apophyses: Locations

Image retrieved from http://www2.luriechildrens.org/ce/online/article.aspx?articleID=101

Ages of Fusion of Hip Apophyses

Iliac Crest – 15 to 17 years

Ischial Tuberosity – 19 to 25 years

ASIS – 21 to 25 years

AIIS – 16 to 18 years

Lesser Trochanter – 16 to 18 years

Greater Trochanter – 16 to 18 years

Apophysitis

Definition

Overuse injury

Inflammation at sites of tendon

attachment

Traction forces

Growth plate is the weak link

Iliac Crest Apophysitis

Most common

Involves abdominal and gluteal muscles

Presents with anterior and superior hip pain with

activity

Iliac crest ossification center closes anterior to

posterior

Females between 14 to 18

Males between 16 to 20

Long distance runners and dancers

Image retrieved from http://eorif.com/iliac-apophysitis-7329

Hip Apophysitis: Clinical Presentation

Tenderness to palpation over anterior half of iliac crest, ASIS, or AIIS, lesser trochanter or greater trochanter

Reproducible pain with resisted hip abduction or trunk rotation

Tenderness is over bony prominences rather than muscles or tendons

X-rays should be obtained to rule out an avulsion fracture

Hip Apophysitis: Differential Diagnosis

Sports hernia

Hip strains

Stress fractures

Osteitis pubis

Intra-articular hip pathology

Labral tears, hip osteoarthritis, chondral

lesions, and femoroacetabular impingement

Tumors

Hip Apophysitis: Treatment

Treatment

Relative rest

May participate in sport at a level that does not

produce pain

Rest

Ice

Analgesics (anti-inflammatory medication)

Cross training

Slow progression of activities over 4 to 6 weeks

Aggressive hip and abdominal flexibility program

Avulsion Fracture of Hip and Pelvis

When should you consider Surgery

for an Avulsion Fracture?

A. Greater than 1 cm displacement

B. Greater than 2 cm displacement

C. Greater than 3 cm displacement

D. Greater than 4 cm displacement

E. All fractures regardless of displacement

Avulsion Fracture

At-risk athletes:

Sprinters

Soccer players

Gymnasts

Dancers

Football players

Avulsion Fracture of Hip and Pelvis

Skeletally immature athlete

Caused by a sudden violent contraction

Accounts for 11% to 40% of all hip and

pelvis fractures in pediatrics

ASIS (Sartorius) and Ischial Tuberosity

(Hamstrings) most common = 60%

Avulsion Fracture Hip and Pelvis:

Clinical Presentation

Presentation

Athlete will note a sudden pull or

pop during activity

Localized pain and swelling over

bony attachment

Loss of motion

“The following pelvic x-ray is from a 15 year old male. He was running when he heard a ‘pop’ sound and collapsed onto the ground, following which he noted pain around the right groin and down to the knee. What can you note in the x-ray?”

Image and case retrieved from http://www.emergucate.com/2014/01/20/imaging-case-of-the-week-84/

Avulsion Fracture Hip and Pelvis:

Diagnostic Tests

Radiographs

Essential for diagnosis

Comparison views of the

uninvolved side should be obtained

Avulsion Fractures of Hip and Pelvis:

Treatment

Rest, ice, analgesics

Gentle active and passive range of motion

Progressive resistance exercises when 75% of

ROM and 50% strength are reached

Stretching and strengthening combined with

patterned motions

Surgery – rare; consider when displacement is

2 cm or greater

Avulsion Fractures of Hip and Pelvis:

Return to Sport

Full pain free range of motion

Full strength

Able to walk, jog, run, and sprint without

pain

Able to jump on the injured leg without

pain

Usually requires 5 to 10 weeks

Which type of Bursitis is most

common in Sports Medicine?

A. Ischial

B. Trochanteric

C. Iliopectineal

D. Ischiogluteal

Image retrieved from http://www.drlox.com/greater-trochanteric-bursitis/

Hip Bursitis

Definition = An inflammation of fluid filled

sacs over bony prominences and joints

Causes

Repetitive Overuse

Post traumatic or direct injury

Degenerative changes

Systemic disease

Hip Bursitis

3 major hip bursa

Trochanteric

Ischial

Ischiogluteal

Trochanteric Bursitis: Presentation

Pain and tenderness over greater trochanter worsened by hip flexion and extension

Pain may radiate to knee, ankle, or into the buttock

Pain worsened by rising from a seated or recumbent position

Pain improves after a few steps; but, recurs after walking for more than 30 minutes

Pain at night

Most common in athletes especially runners

Trochanteric Bursitis

Causes

Muscle Imbalance between hip abductors and adductors

Leg-length discrepancy

Excessive training

Foot hyperpronation

External factors

Hard surface

Banked track

Shoes

Trochanteric Bursitis: Tests

X-rays of Pelvis and Lateral Hip

Rule out bony abnormalities and intra-

articular hip pathology

Bone scans and MRI

Rarely needed

Helpful to rule out occult fractures,

tumors, or osteonecrosis of the femoral

head

Trochanteric Bursitis: Differential

Diagnosis

Metastatic Tumor

Osteoarthritis of the Hip

Sciatica

Septic arthritis of the hip

Snapping hip

Trochanteric fracture

Trochanteric Bursitis: Treatment

Rest

Ice

Analgesics

Injection of steroid and lidocaine

Stretching program

Address IT band and hip adductors

Address internal causes

Slow progression and return to sport

Surgical management rarely indicated

Traumatic Osteitis Pubis involves the

bony origin of which muscle?

A. Gracilis

B. Iliopsoas

C. Hamstrings

D. Adductor magnus

Osteitis Pubis

Cause of chronic groin pain in athletes

Athletes at risk

Distance runners

Football players

Soccer players

Basketball players

Weight lifters

Fencers

Osteitis Pubis

Caused by repetitive trauma to the pubic

symphysis from muscle strain of the

Gracilis

Leads to inflammatory response

Described as a fatigue fracture

Pathophysiology compared to medial

tibial stress syndrome

Referred to Gracilis Syndrome

Osteitis Pubis: Radiology Findings

Image retrieved from http://www.radpod.org/2007/10/12/osteitis-pubis/

Osteitis Pubis: Clinical Symptoms

Slow insidious onset of dull groin pain

Pain may be midline, unilateral or bilateral

Absence of systemic symptoms

Pain may radiate into lower abdomen,

proximal medial thigh or inguinal area

Can be chronic and incapacitating

Worse with activity

Relieved by rest

Osteitis Pubis: Clinical Findings

Athlete walks with wide based or waddling gait

Tenderness to palpation over pubic symphysis or

pubic tubercle

Pain over pubic symphysis with passive

abduction

Pain with resisted adductor testing

One legged hop test may reproduce groin pain

Osteitis Pubis: Differential Diagnosis

Osteomyelitis

Hip Strain

Hernia

Stress Fracture

Intra-articular hip disease

Referred low back pain

Endometriosis/PID/Tumor

Osteitis Pubis: Diagnostic Tests

X-rays

Rule out avulsion fractures or other bony abnormalities

May lag behind clinical findings by 2 to 4 weeks

MRI

High sensitivity and readily available

Confirmatory test

Ultrasound

Help rule out hernia and has low cost

Bone scan

Obtain when MRI and Ultrasound are equivocal

Osteitis Pubis: Treatment

Condition is generally self-limited

Relative Rest - mainstay of treatment

NSAIDs

Physical Therapy – 6 to 8 weeks

Main goal: strengthen and stabilize the pelvis

and pubic symphysis

Cortisone injections or oral glucocorticoids

Surgical debridement and arthrodesis of pubic

symphysis

Osteitis Pubis: Return to Sport

Can occur when athlete is pain-free

Usually 2 to 3 months with

conservative measures

If surgery needed, could take 1-2

years for athletes to return

Groin Strain

(Adductor muscle strain) Common injury, caused by forceful twisting or pivoting of

the lower extremity

Common sports

Football

Ice hockey

Soccer

Baseball

Karate

Gymnastics

Track sports

Groin Strain

Mechanism of Injury – Forceful contraction of an

overstretched adductor muscle against another

player, the ground or the ball

Risk factors for injury

Older athlete

Inflexibility

Muscle imbalance

Inadequately warmed up muscles

Early in the season

Image retrieved from http://orthopedicsurgerysandiego.com, McKesson Health Solutions

Groin Strain: Presentation

Varied presentation

Pain dull or sharp

Pain localized or diffuse

Radiation into scrotum, hip, medial thigh,

or deep pelvis

Pain worsened by activities involving

forced adduction of the hip

Groin Strain: Physical Exam and

Diagnostic Tests

Tenderness to palpation over pubic bone

Discomfort on passive abduction of the

thigh and resisted adduction of the thigh

Radiographs should be obtained

Bone scan or MRI should be reserved for

rare cases

Groin Strain: Differential Diagnosis

Osteitis pubis

Sports hernia (Athletic pubalgia)

Apophysitis

Lower abdominal muscle strains

Stress fractures

Nerve impingement

Ilioinguinal nerve

Obturator nerve

Intra-articular hip pathology

Groin Strain: Treatment

RICE

Passive stretching and Physical therapy

Isometrics and cycling or walking

Strengthening and weight lifting

Sports specific training and return to sport

Rehab program may take 4 to 6 weeks up

to months or years

Groin Strain: Return to Sport

Full pain free Range of Motion

90% to 95% of preinjury strength as compared to

uninjured leg

Completion of all sports specific activities

Advise athletes to wear pair of compression

shorts or neoprene wrap

Supplies warmth

Supplies support

Supplies proprioceptive assistance

What is the typical Return to Play

for a Grade 2 Hip Strain?

A. 1 to 2 weeks

B. 2 to 3 weeks

C. 3 to 4 weeks

D. 4 to 6 weeks

E. 8 to 12 weeks

Hip Strains: Mechanism of Injury

Hip Flexor Strains

Forceful Contraction of hip flexors while being stretched

Iliopsoas, Sartorius, or Rectus Femoris

Quadriceps Strains

Sudden deceleration of the leg

Violent contraction of the quadriceps

Rapid deceleration of an overstretched muscle

Hamstring Strains

An opposite force applied to a fully stretched hamstring

Sudden stretch applied to hamstring muscle

Hip Strains: Risk Factors

Muscle imbalance between the quadriceps and

hamstrings

Inadequate flexibility

Inadequate warm-up

Strength imbalance between legs

History of previous injury

Muscle fatigue

Poor running form

Overuse injuries

Hip Strains: Clinical Symptoms

Audible pop may be heard or felt

Tenderness to palpation over injured

muscle

Sometimes bruising, swelling, or

palpable gap

Hip Strains: Physical Exam

Hip Flexors

Pain worse with flexion of the hip against

resistance or with passive extension of the hip

Quadriceps

Pain exacerbation with passive flexion of the knee or resisted extension of the knee

Hamstrings

Pain exacerbation with passive extension of the knee and hip flexion and resisted flexion of the

knee and hip extension

Hip Strains: Diagnostic Tests

Plain X-rays

Rule out avulsion fractures, bony

abnormalities, or myositis ossificans

Generally normal

MRI

Can differentiate between Grade 2 and

Grade 3 Strains

Not cost effective

Reserved for elite athletes

Hip Strains: Differential Diagnosis

Hip Avulsion Fractures

Sartorius Strain – avulsion of ASIS

Rectus Femoris Strain – avulsion of AIIS

Osteonecrosis of Hip

Pelvic or proximal femoral tumors

Hip Strains: Treatment

RICE protocol – first 24 to 48 hours

Crutch walking

Anti-inflammatory analgesics

Physical Therapy

Passive stretching and gentle active range of motion

Isometric strengthening

Cross training

Surgical intervention - rare

Steroid injections – Not advisable

Hip Strains: Return to Sport

Full pain-free Range of motion

Quadriceps to Hamstring strength ratio is 0.60 or more

Strength ratio 0.55 or less has 33% chance of reinjury

Strength is 90% to 95% of the uninvolved side

Can complete sports specific activities

Dependent upon Grade

Grade 1 – 1 to 2 weeks

Grade 2 – 3 to 4 weeks

Grade 3 – 8 to 12 weeks

Image retrieved from

http://www.radiologyassistant.nl/en/p4bc9b8ab8ec80/bone-tumor-p-z.html

Which type of Stress Fracture

should be treated Surgically?

A. Compression Side Femoral Neck

B. Femoral Shaft

C. Pelvic

D. Tension Side Femoral Neck

Stress Fracture of Femur and Pelvis

Caused by repetitive micro-traumatic forces to

the bone

Disrupts cycle of bone resorption and bone

repair

Common in military recruits and endurance

athletes

Often misdiagnosed or missed

Classified based on the anatomic location of

the fracture

Stress Fracture: Risk Factors

Training errors

Change in running surface

Inadequate footwear

Osteopenia

Pes planus

Stress Fracture: Clinical Symptoms

Vague pain in the groin, anterior thigh or knee

Pain with activity or weight bearing

Pain resolves with rest

Tenderness to palpation of affected area

Decreased range of motion of hip to IR

Antalgic gait

Pain may develop at a consistent time or

distance

Precipitated by recent increase in activity level

Stress Fracture: Diagnostic Tests

X-rays – usually negative in the first 2 to 4 weeks

Plain films only show changes during the reparative phase

Classic Radiographic signs

Radiolucent lines

Sclerosis

Periosteal new bone formation

Bone scan

Detect stress fractures as soon as 24-48 hours after injury

MRI

Extremely sensitive for Femoral Neck Stress Fracture

Stress Fracture: Differential Diagnosis

Acute fracture of the femoral neck

Muscle strain or groin pull

Hip Osteoarthritis

Hip Osteonecrosis

Pathologic fracture

Pelvic fracture

Acetabular labral tear

Image retrieved from

http://www.eorthopod.com/stress-fracture-

of-the-hip/topic/55

Stress Fracture: Treatment

Pelvic stress fracture

Rest

Protected weight-bearing

Flexibility exercises

Nonimpact activity such as swimming or

cycling

Return to sport may be delayed up to 6

months

Stress Fracture: Treatment

Tension side Femoral neck fracture

Transverse fracture in superior cortex of femur

Older patients

Can progress to displaced fracture – surgical

emergency

Should have internal fixation

Surgery for all

“Compression side femoral stress fracture in a long-distance runner.” Retrieved from

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3495575/figure/bjr-85-1148-g009/ The British Institute of Radiology

Stress Fracture: Treatment

Compression side Femoral neck fracture

Bone changes or fracture line on medial aspect

Younger athletes

Usually treated conservatively

Cessation of activity

Non-weight bearing with crutches

Healing usually occurs in 6 to 8 weeks

Serial Radiographs essential

Surgery rarely necessary

Stress Fracture: Treatment

Femoral shaft

Conservative Tx

Full rest until pain free

Crutch-walk and slowly progress to full

weight bearing when pain free

Cross training with biking or swimming after

6 weeks

Stress Fracture: Return to Sport

Address any intrinsic or extrinsic factors

Dependent upon age, sex, bone density,

and location of fracture

Follow X-rays monthly for the first 3 months

May take up to 2 years for complete healing

Return to sport

Compression and femoral shaft – 6 to 8 weeks

Pelvic and Tension – 6 months to 2 years

What is the most common

Snapping Hip Syndrome?

A. Iliopsoas tendon passing over Iliopectineal

eminence or Lesser Trochanter

B. Iliotibial band passing over the Greater

Trochanter

C. Long head of biceps femoris passing over

Ischial Tuberosity

D. Iliofemoral Ligaments passing over the Femoral

Head

Snapping Hip: Definition

Characterized by a snapping or popping sensation that

occurs as tendons move over bony prominences

Common sites

Iliotibial band snapping over the greater trochanter

Most common

Iliopsoas tendon sliding over the iliopectineal

eminence or lesser trochanter

Long head of biceps femoris sliding over Ischial

Tuberosity

Iliofemoral ligaments over the Femoral head

Image retrieved from

http://www.parkclinic.com.au/home/co

nditions-treatment/hip/snapping-hip/

Snapping Hip: Clinical Symptoms

Snapping sensation with walking or rotation of hip

Snapping when lying with affected side up and

rotation of leg

Associated with trochanteric bursitis

May have pain upon rising in the morning and at

night

Difficulty lying on affected side

Iliopsoas subluxation

Groin pain when hip extends from flexed position

(rising from chair)

Snapping Hip: Clinical Presentation

IT band subluxation recreated by having

the athlete stand and rotate hip while

holding it in an adducted position

Iliopsoas subluxation may be noted as the

hip extends from a flexed position (rising

from chair)

Snapping Hip: Tests

Diagnostic Tests

X-rays of the Pelvis and Lateral Hips

Usually normal

CT Arthrogram

Rule out intra-articular loose bodies

MRI with Gadolinium

Rule out a tear of the acetabular labrum

Snapping Hip: Differential Diagnosis

Osteoarthritis of the hip (limited Internal

Rotation)

Osteochondral loose body

Osteonecrosis of the femoral head

Tear of the Acetabular Labrum

Snapping Hip: Treatment

Education and Reassurance

Activity modification

Short course of non-steroidal anti-inflammatories

Stretching and strengthening exercises

Focus on IT band, hip abductors, hip adductors and

hip flexors

Corticosteroid injections

Trochanteric bursa or Psoas tendon sheath

Surgery – rare

Return to Sport – Immediate

Which muscle is not associated

with the correct Apophyses?

A) Sartorius – Anterior Superior Iliac Spine (ASIS)

B) Transversus abdominus and Gluteal muscles –

Iliac Crest

C) Rectus Femoris – Anterior Inferior Iliac Spine

(AIIS)

D) Adductor and Gracilis – Inferior pubic rami

E) Iliopsoas – Greater Trochanter

When should you consider Surgery

for an Avulsion Fracture?

A. Greater than 1 cm displacement

B. Greater than 2 cm displacement

C. Greater than 3 cm displacement

D. Greater than 4 cm displacement

E. All fractures regardless of displacement

Which type of Bursitis is most

common in Sports Medicine?

A. Ischial

B. Trochanteric

C. Iliopectineal

D. Ischiogluteal

Traumatic Osteitis Pubis involves the

bony origin of which muscle?

A. Gracilis

B. Iliopsoas

C. Hamstrings

D. Adductor magnus

What is the typical Return to Play

for a Grade 2 Hip Strain?

A. 1 to 2 weeks

B. 2 to 3 weeks

C. 3 to 4 weeks

D. 4 to 6 weeks

E. 8 to 12 weeks

Which type of Stress Fracture

should be treated Surgically?

A. Compression Side Femoral Neck

B. Femoral Shaft

C. Pelvic

D. Tension Side Femoral Neck

What is the most common

Snapping Hip Syndrome?

A. Iliopsoas tendon passing over Iliopectineal

eminence or Lesser Trochanter

B. Iliotibial band passing over the Greater

Trochanter

C. Long head of biceps femoris passing over

Ischial Tuberosity

D. Iliofemoral Ligaments passing over the Femoral

Head

QUESTIONS?

REFERENCES

The British Institute of Radiology. Compression side femoral stress fracture in a long-distance runner. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3495575/figure/bjr-85-1148-g009/

D'Souza, MD, Donna. Osteitis pubis. Retrieved from http://www.radpod.org/2007/10/12/osteitis-pubis/ eORIF. Iliac Apophysitis. Retrieved from http://eorif.com/iliac-apophysitis-7329 Imaging case of the week 84. Retrieved from http://www.emergucate.com/2014/01/20/imaging-case-of-the-week-84/ LaBella, C. R. (2005). Location of apophyses in the pelvis and hip. Retrieved from http://www2.luriechildrens.org/ce/online/article.aspx?articleID=101 Lox, Dennis. Greater trochanteric bursitis. Retrieved from http://www.drlox.com/greater-trochanteric-bursitis/ McKesson Health Solutions. Groin strain. Retrieved from http://orthopedicsurgerysandiego.com Orthopod. Stress fracture of the hip. Retrieved from http://www.eorthopod.com/stress-fracture-of-the-hip/topic/55 Park Clinic Orthopedics. Snapping hip. Retrieved from http://www.parkclinic.com.au/home/conditions-treatment/hip/snapping-hip/ van de Woude, Henk Jan & Smithuis, Robin. Typical stress fracture of medial side of the femoral neck. Retrieved from http://www.radiologyassistant.nl/en/p4bc9b8ab8ec80/bone-tumor-p-z.html

References

Peck D, McKeag D, Moeller J: Pelvis, Hip and Upper Leg. ACSM’s

Primary Care Sports Medicine 447-460, 2007

Boden BP, Osbahr DC: High-risk stress fractures: Evaluation and

treatment. J Am Acad Orthop Surg 8:344-353, 2000

Metzmaker JN, Pappas AM: Avulsion fractures of the pelvis. Am J

Sports Med 13:349-358, 1985

Anderson K, Strickland SM, Warren R: Hip and groin injuries in

athletes. Am J Sports Med 29:521-533, 2001

Owens B, Busconi B: Pelvis, Hip and Thigh. Sports Medicine Just the

Facts 337-342, 2005