Dr. Willa Fornetti, DO, MS Primary Care Sports Medicine Non Surgical Orthopedics The Kennedy Center at Mercy Oshkosh, Wisconsin

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1 Dr. Willa Fornetti, DO, MS Primary Care Sports Medicine Non Surgical Orthopedics The Kennedy Center at Mercy Oshkosh, Wisconsin

2 Anterior Hip Pain in Athletes

3 Disclosure- Neither I, Willa Fornetti, nor any family member(s), have any relevant financial relationships to be discussed, directly or indirectly, referred to or illustrated with or without recognition within the presentation.

4 Anterior Hip in Athletes- Overview Anatomy of the Hip Mechanism of Injury Differential Diagnosis History Physical Exam Diagnostic Imaging Causes of Hip Pain Treatment

5 Hip Joint Anatomy Ball and socket synovial joint Multiaxial motion Transfers loads between upper and lower body Articular surfaces covered by hyaline cartilage

6 Hip Joint Anatomy

7 Hip Joint Anatomy

8 Anterior Hip Pain in Athletes- Mechanism

9 Groin Pain in Athletes- Mechanism Stress forces on the groin Abnormal physiologic hip motion required for sport Repetitive motion without adequate rest Muscle imbalance Children doing more earlier leading to the development of hip joint pathology

10 Differential Diagnosis Anterior Hip Pain in Athletes Labral Tear Femoral Acetabular Impingement Osteoarthritis of the Hip Stress Fracture Snapping Hip (Internal) Transient Synovitis, Septic Arthritis Osteonecrosis Hip Flexor Strain Adductor tear/strain Osteitis pubis Sports hernia Apophysitis/Avulsion Hamstring Injuries Myositis ossificans Intra articular loose bodies Tumors- osteoid osteoma Testicular/Epididymal pathology Referred pain (ureteric colic) Infection Cancer Obturator nerve entrapment Seronegative spondarthropathy

11 Anterior Hip Pain Characteristics Inflammatory Mechanical Referred Strained Tissues

12 Anterior Hip Pain Characteristics Red Flag symptoms: Night pain Associated weight loss Associated night sweats Constant pain, unrelieved with analgesics Inability to weight bear Yellow Flag symptoms: Seronegative spondloarthropathy: eyes, skin, gu, bowels

13 Anterior Hip Pain History Onset? Gradual? Injury? Location? Superficial or Deep? Pubic, anterior or lateral hip, lower abdominal? PPQRST Worsens pain? Improves pain? Mechanical symptoms? Reproducible with palpation or motion? Prior imaging studies? Treatments attempted to date? Helpful and for how long? Goals of treatment?

14 Anterior Hip Pain Physical Exam Standing Gait, proprioception, squat, repeated one legged hop Lumbar spine exam Lumbar AROM, standing flexion/stork Alignment Lumbar, SI, pelvis, innominate Leg length discrepancy Hip exam ROM (passive- seated or prone) Log roll, FADIR, FABER, Scour Knee exam Reflexes, neurologic Strength testing- causes pain?

15 Anterior Hip Pain Physical Exam

16 Anterior Hip Pain Physical Exam Log Roll- passive hip ROM Restricted movement? Pain? Stinchfield test- loads the anterior labrum Pain? Weakness?

17 Anterior Hip Pain Physical Exam FADIR- groin pain Scour- groin pain, myofacial tightness, painful click FABER- groin pain

18 Diagnostic Imaging for the Hip Hip X-rays AP Pelvis Frog Leg Lateral Dunn View

19 Diagnostic Imaging for the Hip MRI +/- arthrogram Ultrasound groin with provocation tests CT- 3 D reconstruction

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21 Causes of Anterior Hip Pain- Osteonecrosis Legg-Calve-Perthes disease Idiopathic osteonecrosis of the femoral head in children 2-12 years of age Affects males more than females ratio 5:1 Adults-risk factors include lupus, sickle cell, HIV, smoking, alcoholism and steroid use Pain, insidious onset Treatment depends on severity NSAIDS, relative rest, activity restriction and physical therapy Casting, immobilization and crutches Surgical treatment

22 Causes of Anterior Hip Pain- Slipped Capital Femoral Epiphysis (SCPE) Slipped capital femoral epiphysis (SCPE) Adolescent hip during growth spurt Patient is usually overweight 2-3 more common in males than females Pain, insidious onset. Limp, leg turns outwards Goal of surgical treatmentprevent any additional slipping of the femoral head until the growth plate closes. Complication- avascular necrosis (AVN) Urgent pediatric ortho consult

23 Causes of Anterior Hip Pain- Infectious Acute onset, atraumatic Impaired weight bearing Transient Synovitis Children 3-10 yrs old Most common cause of hip pain and limp Recent viral infection commonly cited although true in only 30% cases Diagnosis of exclusion NSAIDS, limit weight bearing Usually clears by itself in 7-10 days Septic Arthritis Older adults > 80 yrs old Diabetes, RA Recent joint surgery and hip or knee prostheses Septic Joint Fevers? Travel? Bloodwork includes: CBC, sed rate, CRP MRI without contrast If effusion then perform image guided aspiration Fluid analysis- cell count and gram stain, cultures Positive cultures- proceed with urgent orthopedic consultation Surgery to wash out the joint, IV/oral antibiotics Older patients may require urgent joint replacement

24 Causes of Anterior Hip Pain- Hip Fracture Occult or stress fracture Gradual onset with exercise Pain with running, then walking Marathon runner Can be associated with female athlete triad Treatment depends on location and severity of the stress fracture Compression side Medial, inferior non weight bearing, activity restrictions Tension side Superior, lateral ORIF and percutaneous screw fixation Pathologic fractures include osteoporosis, tumors and infections

25 Causes of Anterior Hip Pain- Iliopsoas Bursitis (Internal Snapping Hip) Anterior hip pain when extending the hip from a flexed position Young athletes during rapid growth- tight anterior musculature with weak glut/hip/core More common in sports with repetitive hip flexion Dynamic ultrasound is useful in evaluating snapping hip Physical therapy/rehabilitation

26 Causes of Anterior Hip Pain- Labral Tear Dull or sharp groin pain Pain usually insidious onset but can be after trauma 50% patients have mechanical symptoms MRI arthrogram helpful for diagnostic evaluation Surgical vs Non Surgical treatment

27 Causes of Anterior Hip Pain- Femoral Acetabular Impingement (FAI) Abnormal contact between the femoral head and acetabulum during normal or athletic activity Bone spurs develop around the femoral head and/or along the acetabulum. Up to 90% of hips with labral tears also have FAI pathology Breakdown of articular cartilage leads to osteoarthritis Congenital abnormalities can contribute Sports accelerate process Common cause of intra articular hip pain and early osteoarthritis

28 Causes of Anterior Hip Pain- Femoral Acetabular Impingement (FAI) Pain usually begins gradually but can be sudden onset Pain occurs with activities requiring flexion, adduction and internal rotation of the hip Sports/exercise but also prolonged sitting, getting in and out of a car Cam impingement is usually found in men, manifests between ages Pincer more in women present slightly older Most cases are mixed pattern Problems occur mainly at the anterolateral femoral head/neck junction and anterior/superior acetabulum.

29 Anterior Hip Pain in Athletes- FAI Physical Exam Log roll- 56% sensitive for FAI Stinchfield- 30% sensitive for FAI FADIR 88% sensitive for FAI 96-75% sensitive for labral tears Scour FABER 96-99% sensitive for FAI 88% sensitive for labral tears Imaging X-rays MRA arthrogram used to assess cartilage and labral tears Intra articular anesthetic injection may confirm source Measurement of the alpha angle for CAM Measurement of overcoverage of the acetabulum or Pincer

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32 Causes of Anterior Hip Pain- Osteoarthritis Gradual onset of pain, worse over time More common in older patients (>40 years) Pain typically dull but sharp with weight bear and pivot motion Unable to cross her right foot over knee when putting on socks or shoes Antalgic gait Narrowing of the joint space, bone spurs, sclerosis

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35 Treatment for Anterior Hip Pain Education Activity modification Ice and/or Heat Home exercises Physical therapy Medications Cortisone injection Surgery

36 MSK Treatment for Anterior Hip Pain Causation? Multiple Interdependent Pathologies Groin Pain Hip flexor tightness Lumbar lordosis Lumbar dysfunction QL and TFL tightness Asymmetrical sheer force across the symphysis Osteitis pubis Adductor and Iliopsoas spasm and strain

37 MSK Treatment for Anterior Hip Pain Principles: Mobilize and stabilize lumbar spine Relieve QL & TLF tightness Relieve neural tension Relieve iliopsoas tightness Strengthen and balance adductors & abdominals Strengthen gluteal musculature Correct leg length discrepancy

38 Treatment for Femoral Acetabular Impingement Non operative treatment Rest NSAIDS Core/hip strengthening Physical Therapy Surgical treatment Arthroscopic or open Goal is to restore normal joint morphology Osteoplasty of the femoral neck Trimming of the acetabular rim Torn labrum debrided or repaired

39 Efficacy of Surgical Treatment for FAI 23 articles included in this systematic review 608 males, 362 females; mean age of the patients were 34.8 yrs Does surgical treatment for FAI succeed in improving patient symptoms? Both arthroscopic and open treatment, improved mean postoperative scores In which patients should standard treatment for FAI be avoided? 0-30% dissatisfied and went onto have THA Outerbride grade 3 or 4 cartilage injury seen intraoperative and OA greater than Tonnis grade 1 on preoperative radiographs were associated with poorer outcomes Is labral refixation superior to labral resection? Studies varied in their treatment of labral injury 2 studies- hip function, pain scores and delay of radiographic OA improved more with labral refixation (1 study), another found no significant difference Does treatment for FAI affect the progression of OA? Difficult to determine Cases were relatively recent and OA is a gradual process. Ng, Arora, Best et al. Efficacy of Surgery for Femoroacetabular Impingement. Clin Sports Med Update. 2010; 38(11):

40 Surgical Treatment for FAI in Athletes Systematic review of 9 studies 418 athletes surgically treated for FAI Mean age was 25.4 years (range from 11 to 66 yrs) Return to sport- 92% Rate of return to the previous level of competition- 88%. Professional athletes- rate of return 95%, return to preinjury activity levels was 92% Level 4 studies (case series) but findings suggest that surgical treatment for FAI resulted in a high return to preinjury activity levels of sports. Alradwan, Philippon, Farrokhyar et al. Return to Preinjury Activity Levels After Surgical Management of Femoral Acetabular Impingement in Athletes. Journal of Arthroscopic and Related Surgery. Vol 28, No 10 (Oct), 2012: pp

41 Treatment for Anterior Hip Pain Education Activity modification Ice and/or Heat Home exercises Physical therapy Medications Cortisone injection Surgery

42 Anterior Hip Pain in Athletes Review Anatomy of the Hip Mechanism of Injury Differential Diagnosis History Physical Exam Diagnostic Imaging Causes of Hip Pain Treatment

43 References Alradwan, Philippon, Farrokhyar et al. Return to Preinjury Activity Levels After Surgical Management of Femoral Acetabular Impingement in Athletes. Journal of Arthroscopic and Related Surgery. 2012; Vol 28(10): Beall, Sweet, Martin et al. Imaging findings of femoral acetabular impingement syndrome. Skeletal Radiol. 2005; 34 (11): Burnett, Della, Prather et al. Clinical presentation of patients with tears of the acetabular labrum. J Bone Joint Surg Am. 2006; 88 (7): Bedi, Kelly. Current Concepts Review: Femoroacetabular Impingement. J Bone Joint Surg Am. 2013; 95: Clohisy, Knaus, Hunt et al. Clinical presentation of patients with symptomatic anterior hip impingement. Clin Orthop Relat Res. 2009; 467 (3): Czerny, Hofmann, Neuhold et al. Lesions of the acetabular labrum: accuracy of MR imaging and MR arthrography in detection and staging. Radiology. 1996; 200(1): Fullerton, Snowdy. Femoral neck stress fractures. Am J Sports Med. 1988; 16 (4): Gomberawalla, Kelly, Bedi. Interventions for hip pain in the maturning athlete: the role for hip arthroscopy? Sports Health.2014; 6(1): Gough-Palmer, McHugh. Investigating hip pain in a well child. BMJ. 2007; 334 (7605): Hendry, England, Kenter, Wissman. Femoral Acetabular Impingement. Seminars in Roentgenology. 2013; 48(2): Ito, Leunig, Ganz. Histopathologic features of the acetabular labrum in femoroacetabular impingement. Clin Orthop Relat Res. 2004; 429: Kocher, Zurakowski, Kasser. Differentiating between septic arthritis and transient synovitis of the hip in children. J Bone Joint Surg Am. 1999; 81 (12): Ng, Arora, Best et al. Efficacy of Surgery for Femoroacetabular Impingement. Clin Sports Med Update. 2010; 38(11): Wenger, Kendell, Miner, Trousdale. Acetabular labral tears rarely occur in the absence of bony abnormalities. Clin Orthop Relat Res. 2004; 425: Wilson, Furukawa. Evaluation of the patient with hip pain. American Family Physician. 2014; 89(1):

44 Questions?? Dr. Willa Fornetti, DO, MS Primary Care Sports Medicine Non Surgical Orthopedics The Kennedy Center at Mercy Oshkosh, Wisconsin

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