HipHip Pathology in the Adolescent athlete Pathology in the Adolescent athlete

Dr.EMAD KARIMDr.EMAD KARIM

This article will review the more common This article will review the more common causes of hip and groin pain in the causes of hip and groin pain in the

adolescent athleteadolescent athlete , ,

as well as advances in diagnostic and as well as advances in diagnostic and therapeutic interventionstherapeutic interventions..

Risk factorsRisk factors to adolescent hip pathology includeto adolescent hip pathology include::

musculoskeletal balancemusculoskeletal balance

open physes and growingopen physes and growing

Physical examinationPhysical examination Patients with intra-articular hip pain place a hand in the shape of a C around the hipPatients with intra-articular hip pain place a hand in the shape of a C around the hip..

Groin pain often has an intraarticular etiology lateral hip pain is usually associated Groin pain often has an intraarticular etiology lateral hip pain is usually associated with extraarticular causeswith extraarticular causes . .

Isolated posterior buttock pain is often related to lumbar and sacroiliac joint Isolated posterior buttock pain is often related to lumbar and sacroiliac joint dysfunctiondysfunction..

Physical examination of the hip includes The four Physical examination of the hip includes The four layers : osseous, cartilaginous, muscular, and layers : osseous, cartilaginous, muscular, and neural. neural.

The examination includes evaluation of gait and The examination includes evaluation of gait and physical tests in the standing, supine, lateral, and physical tests in the standing, supine, lateral, and prone positions.prone positions.

Trendelenburg patterns manifest as lateral trunk Trendelenburg patterns manifest as lateral trunk flexion while shifting weight over the stance leg.flexion while shifting weight over the stance leg.

The (FABER) test is used to diagnose injuries to the The (FABER) test is used to diagnose injuries to the labrum.labrum. The anterior impingement test is performed with the The anterior impingement test is performed with the patient in the supine position; the hip is flexed to 90°, patient in the supine position; the hip is flexed to 90°, and a dynamic assessment of the hip joint is performed and a dynamic assessment of the hip joint is performed with flexion,adduction, and internal rotation.with flexion,adduction, and internal rotation.

The scour test is performed with the patient in the The scour test is performed with the patient in the supine position. The hip is brought to 90° of flexion and supine position. The hip is brought to 90° of flexion and abducted, followed by compression with internal and abducted, followed by compression with internal and external rotation.external rotation.

Acetabular Labral Tears Injury is a source of hip pain.Acetabular Labral Tears Injury is a source of hip pain. 5 Injury may occur as a result of hypermobility or 5 Injury may occur as a result of hypermobility or repetitive mechanical stresses with excessive flexion repetitive mechanical stresses with excessive flexion and rotation. and rotation.

Underlying bony disorders of the hip, such as hip Underlying bony disorders of the hip, such as hip dysplasia, femoral retroversion, coxa valga, and dysplasia, femoral retroversion, coxa valga, and slipped capital femoral epiphysis, can place the labral slipped capital femoral epiphysis, can place the labral tissue at a greater risk of tear.tissue at a greater risk of tear.

Acetabular labral tearsAcetabular labral tears

commonly found in the anterior superior aspect of the commonly found in the anterior superior aspect of the acetabulum.acetabulum.

These tears usually present with sharp anterior hip and These tears usually present with sharp anterior hip and groin activity related pain.groin activity related pain.Pain is described as sharp or pinching and is usually with Pain is described as sharp or pinching and is usually with locking.locking.

anterior impingement and FABER test may be positive.anterior impingement and FABER test may be positive.

Magnetic resonance arthrography is the most reliableMagnetic resonance arthrography is the most reliablestudy .study .

T2-weighted axial magneticT2-weighted axial magneticresonance arthrogramresonance arthrogramdemonstrating a tear of thedemonstrating a tear of theanterosuperior labrum (arrow).anterosuperior labrum (arrow).

Nonsurgical treatment for labral tears :

intra-articular injections (diagnostic and therapeutic).

rest, activity modification,Oral anti-inflammatory medication,and physical therapy.

Hip arthroscopy It is : the preferred surgical approach for the management of isolated labral tears.

safe and effective، good results

Study

30 patients underwent arthroscopic debridement.

At 17-month follow-up:significant improvements were found in the Harris hip score (preoperative, 57.6; postoperative, 89.2).

Three of the patients in this group experienced a recurrent labral tear.

Femoroacetabular Impingement

(FAI) is a process by which a nonspherical femoral head exists within a hemispheric acetabulum, leading tolabral and chondral pathology and hip arthritis.

Patients present with anterior groin pain, which is worsened by flexion and rotation of the hip.

Round lucencies seen in the femoral neck due to a herniation of synovium through a cortical defect.

A peripheral compartmentA peripheral compartmentarthroscopic view of an arthroscopic view of an adolescent hip following adolescent hip following femoral osteoplasty for femoral osteoplasty for the management of the management of impingement.impingement. The proximal femoralThe proximal femoralphysis is visualized.physis is visualized.

Surgical management of Surgical management of FAI is:FAI is:aimed at correcting the aimed at correcting the abnormal osseous abnormal osseous anatomy. anatomy. Both arthroscopic and Both arthroscopic and open techniques have open techniques have been successful.been successful.

Coxa saltans is classified as intra Coxa saltans is classified as intra articular,internal, or external.articular,internal, or external.

The intra-articular variant is the result of :The intra-articular variant is the result of :labral tears,loose bodies, or cartilage flaps withlabral tears,loose bodies, or cartilage flaps within the hip joint.in the hip joint.

Coxa saltans external is usually associated with Coxa saltans external is usually associated with snapping of the iliopsoas tendon band or the snapping of the iliopsoas tendon band or the anterior border of the gluteus maximus muscle anterior border of the gluteus maximus muscle over the greater trochanter.over the greater trochanter.

Patients with symptomatic internal snapping hip Patients with symptomatic internal snapping hip syndrome often present with anterior groin pain syndrome often present with anterior groin pain and snapping.and snapping.

A dynamic external rotation test may reproduce A dynamic external rotation test may reproduce snapping or pain.snapping or pain.

Recurrent snapping of the psoas tendon mayRecurrent snapping of the psoas tendon maycause impingement on the labrum and lead to cause impingement on the labrum and lead to labral tears.labral tears.

TreatmentTreatment nonsurgical treatment of symptomaticnonsurgical treatment of symptomaticcoxa saltans externa consists of stretching, coxa saltans externa consists of stretching, physical therapy, (NSAIDs), and corticosteroid physical therapy, (NSAIDs), and corticosteroid injections.injections.

Surgical intervention:Surgical intervention:open surgery or arthroscopic to lengthen the open surgery or arthroscopic to lengthen the iliopsoas tendon band and manage associated iliopsoas tendon band and manage associated trochanteric bursitistrochanteric bursitis

Apophyseal AvulsionsApophyseal Avulsions

commonly encountered around the adolescent commonly encountered around the adolescent hip because of the inherent weakness of the hip because of the inherent weakness of the remaining open physis combined with repetitive remaining open physis combined with repetitive stress to the epiphyseal plate.stress to the epiphyseal plate. These injuries result from indirect trauma These injuries result from indirect trauma caused by a sudden forceful muscular caused by a sudden forceful muscular contractioncontraction

Avulsion injuries are commonly seen in athletes whose Avulsion injuries are commonly seen in athletes whose sports require rapid acceleration and deceleration.sports require rapid acceleration and deceleration.

Study: In 203 avulsion fractures ischial tuberosity Study: In 203 avulsion fractures ischial tuberosity 54% anterior inferior iliac spine fractures 22%, and 54% anterior inferior iliac spine fractures 22%, and anterior superior iliac spine fractures 19%.anterior superior iliac spine fractures 19%.

Patients present with acute pain and swelling that Patients present with acute pain and swelling that follows a sudden, noncontact traumatic incident. follows a sudden, noncontact traumatic incident. tenderness to palpation and pain with passive stretch tenderness to palpation and pain with passive stretch of the muscle attached to the avulsed fragment. of the muscle attached to the avulsed fragment.

Radiographic evaluation is to confirm the diagnosis and Radiographic evaluation is to confirm the diagnosis and allows to assess the size of the avulsed fragment and allows to assess the size of the avulsed fragment and the amount of fracture displacement.the amount of fracture displacement.

The initial management rest, ice,NSAIDs, and The initial management rest, ice,NSAIDs, and protected weight bearing with crutches until symptoms protected weight bearing with crutches until symptoms resolve; physical therapy. resolve; physical therapy.

surgical indications :are for ischial tuberosity fractures surgical indications :are for ischial tuberosity fractures with >2 cm displacement and for symptomaticwith >2 cm displacement and for symptomaticnonunion, chronic pain, and impaired function.nonunion, chronic pain, and impaired function.

Arthroscopic images of iliopsoas tendon lengthening. Arthroscopic images of iliopsoas tendon lengthening. A, A, The iliopsoas tendon (arrow) identified via a transcapsular The iliopsoas tendon (arrow) identified via a transcapsular approach in the central compartment.approach in the central compartment.B, B, The tendinous portion is lengthened under direct visualization (arrow).The tendinous portion is lengthened under direct visualization (arrow).

AP radiograph of a 13-year-AP radiograph of a 13-year-old boy with right anterior old boy with right anterior superior iliac spine avulsion superior iliac spine avulsion fracture (arrow).fracture (arrow).

AP radiograph of a 14 years-old AP radiograph of a 14 years-old girl demonstrating a right girl demonstrating a right lesser trochanteric avulsion lesser trochanteric avulsion fracture (arrow).fracture (arrow).

AP radiograph (AP radiograph (AA) and AP () and AP (BB) and lateral () and lateral (CC) three-dimensional CT ) three-dimensional CT images demonstrating evidence of subspine impingement from a images demonstrating evidence of subspine impingement from a previous anterior inferior iliac spine avulsion fracture (arrow), which previous anterior inferior iliac spine avulsion fracture (arrow), which later required arthroscopic decompression and labral repairlater required arthroscopic decompression and labral repair

Hip Instability Hip Instability classified as traumatic or atraumaticclassified as traumatic or atraumatic

Traumatic hip dislocation generallyresults from an Traumatic hip dislocation generallyresults from an axially applied force against a flexed knee with the axially applied force against a flexed knee with the hip in the neutral or adducted position.hip in the neutral or adducted position.

Generally follows a high-energy trauma,Generally follows a high-energy trauma,and associated injuries are common. and associated injuries are common.

clinicaly severe pain and the hip held in the flexed, clinicaly severe pain and the hip held in the flexed, adducted, and internally rotated position.adducted, and internally rotated position.

Plain radiographs confirm the diagnosis, and Plain radiographs confirm the diagnosis, and emergent reduction is indicated.emergent reduction is indicated.

Following reduction,plain radiographs and Following reduction,plain radiographs and CTCTor MRI are indicated to confirm a congruent or MRI are indicated to confirm a congruent reduction and to evaluate for intra-articular reduction and to evaluate for intra-articular pathology.pathology.

Hip Instability Hip Instability

Management of hip instability restricted weight bearing for 6 weeks postreduction management.

consider capsular or other soft-tissue laxity as a cause of persistent hip instability. Initially,this is managed with physical therapy.

Arthroscopic thermal capsulorrhaphy hasalso Arthroscopic thermal capsulorrhaphy hasalso been proposed.been proposed.

In patients with a nonconcentric reduction or In patients with a nonconcentric reduction or notable acetabular fracture of the posterior wall, notable acetabular fracture of the posterior wall, surgical intervention should be undertaken.surgical intervention should be undertaken. Arthroscopy has been used to removeArthroscopy has been used to removeloose bodies.loose bodies.

Management of hip instability Management of hip instability

SummarySummary

It is the role of the pediatric orthopaedic surgeon and sports It is the role of the pediatric orthopaedic surgeon and sports medicine provider to properly diagnose and manage Hip medicine provider to properly diagnose and manage Hip pathology in the adolescent athlete.pathology in the adolescent athlete.

Appropriate workup and management can be often used Appropriate workup and management can be often used effectively in adolescent athlete.effectively in adolescent athlete.

Nonsurgical management includes activity modification, physical Nonsurgical management includes activity modification, physical therapy and anti-inflammatory medication therapy and anti-inflammatory medication

Surgical management of both intra- and extra-articular hipSurgical management of both intra- and extra-articular hippathology can safely be used when clinically indicated.pathology can safely be used when clinically indicated.