Millers - Sports Medicine - Section 2 Thigh, Hip, And Pelvis

Front 1

Iliac crest contusions

Back 1

(“hip pointer”)—Direct trauma to this area can occur in contact sports. An avulsion of the iliac apophysis should be ruled out in adolescent athletes. Treatment consists of ice, compression, pain control, and placing the affected leg on maximum stretch. Corticosteroid injections have occasionally been advocated. Additional padding is indicated after the acute phase.

Front 2

Groin contusions

Back 2

—An avulsion fracture of the lesser trochanter, traumatic phlebitis, thrombosis, or femoral neuropathy must be ruled out before supportive treatment is initiated.

Front 3

Quadriceps contusions

Back 3

—This can result in hemorrhage and late myositis ossificans. Acute management includes cold compression and immobilization in flexion. Close monitoring for compartment syndrome is indicated in the acute phase.

Front 4

Hamstring strain

Back 4

—This common injury is often the result of sudden stretch on the musculotendinous junction during sprinting. These injuries can occur anywhere in the posterior thigh. Treatment is supportive, followed by stretching and strengthening. To prevent recurrence, return to play should be delayed until strength is approximately 90% that of the opposite side.

Front 5

Athletic pubalgia

Back 5

 “sports hernia”—Common in sports such as soccer, these injuries must be differentiated from subtle hernias. Injury to the muscles of the abdominal wall or adductor longus produce anterior pelvis and/or groin pain without the classic physical findings of a true inguinal hernia. This injury can result from acute trauma or microtrauma associated with overuse of the affected muscle. Rule out other causes of pain with an x-ray, bone scan, and/or MRI. Treat nonoperatively for 6-8 weeks with rest and therapy. Repair or reinforcement of the anterior abdominal wall is indicated after failed conservative measures and after other causes have been excluded.

Front 6

Rectus femoris strain

Back 6

—Acute injuries are usually located more distally on the thigh, but chronic injuries are usually nearer the muscle origin. Pain is elicited with resisted hip flexion or extension. Treatment includes ice and stretching/strengthening.

Front 7

Ilioinguinal nerve entrapment

Back 7

—This nerve can be constricted by hypertrophied abdominal muscles as a result of intensive training. Hyperextension of the hip may exacerbate the pain that patients experience, and hyperesthesia symptoms are common. Surgical release is occasionally necessary.

Front 8

Obturator nerve entrapment

Back 8

—Can lead to chronic medial thigh pain, especially in athletes with well-developed hip adductor muscles (e.g., skaters). Nerve conduction studies are helpful for establishing the diagnosis. Treatment is usually supportive.

Front 9

Lateral femoral cutaneous nerve entrapment

Back 9

—Can lead to a painful condition known as meralgia paresthetica. Tight belts and prolonged hip flexion may exacerbate symptoms. Release of compressive devices, postural exercises, and NSAIDs are usually curative.

Front 10

Sciatic nerve entrapment

Back 10

—Can occur anywhere along the course of the nerve, but the two most common locations are at the level of the ischial tuberosity and by the piriformis muscle, known as “piriformis syndrome.”

Front 11

Stress fractures

Back 11

—A history of overuse, an insidious onset of pain, and localized tenderness and swelling are typical. A bone scan can be diagnostic, even with normal plain radiographs. MRI is the most specific test for detecting stress fractures. Treatment includes protected weight bearing, rest, cross-training, analgesics, and therapeutic modalities. There are several especially problematic stress fractures.

Front 12

Femoral neck stress fractures

Back 12

Tension (transverse) fractures are more serious than compression fractures (on the medial side of the neck) and may require operative stabilization.

Front 13

Femoral shaft stress fractures

Back 13

—Usually respond to protected weight bearing but can progress to complete fractures if unrecognized. The “fulcrum” test may be helpful in making this diagnosis.

Front 14

Proximal femoral fractures

Back 14

—Can occur in athletes, especially cross-country skiers (skier's hip). Release bindings have reduced the incidence of these injuries.

Front 15

Osteitis pubis

Back 15

—Repetitive trauma can cause an inflammation of the symphysis. It occurs frequently in soccer players, hockey players, and runners. Conservative management is usually curative.

Front 16

Labral tears of the hip

Back 16

—Often a cause of mechanical hip pain presenting with vague symptoms. An MR arthrogram has a greater than 90% sensitivity and is often used for diagnosis, but arthroscopy is the gold standard (Fig. 4–29). The highest incidence of labral tears is present in patients with acetabular dysplasia. Underlying hip pathology should be addressed in addition to the labral tear for the best results. Arthroscopic labral d?bridement has shown good short- and mid-term results. New techniques and data that suggest that labral repair may yield better results than debridement are beginning to emerge.

Front 17

Chondral injuries of the hip

Back 17

—Articular surface injury is often a cause of mechanical hip pain. Microfracture is effective in the treatment of focal lesions.

Front 18

Ruptured ligamentum teres

Back 18

—Associated with mechanical hip pain as the ruptured ligament catches within the joint after a hip dislocation. D?bridement is often necessary. The viability of the femoral head is not in jeopardy with a ruptured ligamentum teres.

Front 19

Femoroacetabular impingement (FAI)

Back 19

—A frequent initiator of arthritis in the nondysplastic hip. Impingement may be caused by acetabular retroversion; an old slipped capital femoral epiphysis (SCFE); a nonspherical head; decreased femoral offset or decreased head-to-neck ratio (the Cam effect); overhang of the anterosuperior acetabular rim (pincer mechanism); protrusio; and a retroverted femoral neck (postfracture). Treatment options include open or arthroscopic procedures to trim the femoral head/neck or acetabular rim, periacetabular osteotomy, femoral osteotomy, combinations of the above with labral debridement, and repair. Total hip arthroplasty (THA) is reserved for those with significant arthritic changes.

Front 20

Snapping hip

Back 20

Condition in which the iliotibial band abruptly catches on the greater trochanter or the iliopsoas impinges on the hip capsule. The iliotibial condition (external snapping hip) is more common in females with wide pelvises and prominent trochanters and can be exacerbated by running on banked surfaces. The snapping may be reproduced with passive hip flexion from an adducted position. Stretching/strengthening, modalities such as ultrasonography, and occasionally surgical release may relieve the snapping. This condition must be differentiated from the less common snapping iliopsoas tendon (internal snapping hip), which can be diagnosed with extension and internal rotation of the hip from a flexed and externally rotated position. Arthrography and/or bursography may also be helpful in making the diagnosis.