Hip Pain in Athletes, Dr. Seung Jin Yi

All right. So let’s start out here. We talk about hip pain in athletes especially groin pain.
So what do you do when you have a 19 year old male coming in right hip anterior pain with hip pledging activities. What kind of things can be going on and let’s think about that while we go through some of these different topics with hip and groin pain.
So first topic is femoroacetabular impingement labral tear. So it’s usually patients that are complaining of hip pain with hip flexion activities. And this is due to an impingement in the hip so the femoral neck kind of hits against the anterior edge acetabulum. And this may cause pain and because the labrum is a structure between the tabular socket and the femoral neck. You can imagine that can kind of get crushed between those two bones and the femoral impingement can happen mainly due to a pincer lesion which means the abnormal growth of bone on the acetabulum side or due to a cam lesion which is more of an abnormal bone on the femoral side. And I would say that majority of patients have a combination of these. I typically see that more males tend to have a cam lesion and more females into tend to have a pincer lesion. But they all had this to a growing degree in a combination. Oftentimes when patients come in with hip pain and with impingement things, they’ll usually complain of what’s called the C side.
So when they come in seeing me and they kind of cut their hands like this to look like the letter C and when I asked them hey where does it hurt and they go kind of right in here Doc and they kind of get to the side of that hip and do that motion there.
I usually kind of think maybe this may be related to an FAI or labral type of pathology. I think it’s just a way for the patient to show that it’s deeper inside the hip joint. And it’s not just superficially kind about in their true interpersonal or somewhere else that it’s a deeper pain inside the hip joint in terms of physical examination.
Every single patient you know we always talk about doing everything consistently the same.
So every one of my patients because I have to rule out if this is due to arthritis or other problems I always do the same exams so the first thing I do is I see that external rotation interpretation in the office. And that’s kind of my test for arthritis. They got pain with this. And I think the problem is more arthritis related and not really impingement or other things related. So I will do an internal and external rotation the next second thing is I see a lot of patients that come in with greater troch bursitis. A lot of times it’s funny because I get excited looking at their x rays and see oh my gosh you got terrible arthritis or you get terrible Cam lesion and all they’re saying you stop. No that’s not what bothers me. It just hurts me right over the tip of the greater trip. Whenever I lay on it. And that’s usually probably the more common thing that I see my office which is a fairly easy solution which I just inject them with cortisone and haven’t good therapy.
The other I also make a point of doing, is hip flexion impingement as I just have them lay down and I kind of bend their hip up arm and if they say yeah that that’s exactly it, that’s what kind of get bothers me, then that clues me into doing a little bit more of any exam. Kind of get art geared towards testing for from us our impingement which would be my money test is the failure exams that’s the flexion adduction internal rotation sometimes. It’s called dynamic internal rotation test but what I basically do is I flex their hip up 90 degrees or more and then add up the hip and kind of roll that across and if they have pain with this this is a test where they have this. And even if the MRI is normal, I tell them you got a labral tear and you got impingement. there’s no doubt about it because that’s usually the only thing that really would cause this pain and the entire aspect of the hip with me doing this.
Oftentimes when we get the x rays you can see a little pincer lesion is pointed out by the arrow or a spherical femoral head and neck junction where you can see that there’s a little bit of Cam lesion the next step is usually getting an MRI are through gram which usually shows the label tear.
This is an important point for the primary care physicians. Lot of times I get patients sent to my office that say oh I saw a bunch other doctors my primary care got an MRI and it doesn’t show a labral tear but they wanted me to come see you for you know to see if it’s something else. So if you get a regular MRI the accuracy of that test for a hip labral tear is only 42 percent so it’s less than a coin flip. So it’s very important that if you are truly trying to assess for a labral tear in the hip that you need to get an MR arthrogram with that injected into your hip joint. This is just like in the shoulder you know if you’re looking for a rotator cuff tear then a simple MRI is fine. But if you’re looking for more of a liberal tear than that even in the shoulder, that requires that MR arthrogram to inject a little bit of dye so that we can see that signal cutting across that labrum a little better on this hip with that dye contrast in their terms of treatment for every line labral tear.
You know we often try conservative management with physical therapy for hip stretching and abductor strengthening. So, it’s very important that you know the point of sending someone with FAI labral tear to therapy is not so that we can regain more motion through hip flexion. Right. I mean they have a mechanical block and it’s really more for pain relief and strengthening and stability lies in their head. Not really trying to regain motion that they say they cannot get due to the impingement. And then if that fails down the road.
We’re often doing a labral tear repair. A plus meaning we saved on that little pincer lesion and then femoral plastic meaning we saved on that can lesion.And so this is kind of a typical setup with arthroscopy and we’re taking a little bird device there and taking off that neck lesion in that Cam.And this is what it looks like in the operating room in terms of reshaping the femoral neck.
The next topic is Coxa Saltans or the popping hip, so oftentimes patients come in and a lot of times you know it’s for the knee. People say oh well you know my knee pops and it’s usually normal. Maybe a a band or it may just be that some people just have joints that part and it’s usually not a big deal as long as it doesn’t cause pain my knees pop all the time. I still play soccer and I don’t have any problems but sometimes that popping maybe due to a pathology which maybe an interactive killer loose body sometimes a displaced labral tear can cause popping as well.
And then sometimes you can have a tear in your cartilage that may be popping with certain types of motion and that may be bothering you know. The other types of popping that patients can have is Coxa saltans and turnout or the Ilispsoas popping in inside the hip joint and it usually snaps over the iliopectineal eminence or the femoral head and often the treatment is if it’s not too bad we’d rather stretch anti-inflammatory as hopefully whatever is irritated from the popping episodes go away and they may continue to pop but as long as it doesn’t cause you a whole lot of pain we don’t really do anything with that.
And then if patients are continuing to have problems, we may talk about an injection to see if I can calm it down and also to see if that could be a diagnostic for a true hip pathology.
And then if that doesn’t work then we do a little surgical relief to go in there and just released that earlier so tendon they may lose just a small amount of strength but it usually gets rid of their pain very predictably.
Another type of popping could be an external clot popping costs also as external. And that’s usually due to a snapping of the IT band of the greater trochanter and these patients often come in and say hey dad I got this really cool trick like I can make my hip hop and they can actually show you very well in going from flex to an extended position on and that they’re able to show it to a lot of times. It doesn’t really bother people but patients to want to get checked out if it does bother people then we make sure they do a nice regimen of therapy stretching out their IT band correcting their weaknesses and then playing with toys and maybe even an injection is a both diagnostic and therapeutic treatment. And then if that doesn’t work, we can also do a little IT band and release or whether that’s open or arthroscopic the results have been pretty similar and that’s what we’re able to do for that. Other things that can happen in the groin that think can be confusing sometimes all they had was just a little bit of an adductor injury or they have an adductor tendonitis.
So that’s actually a very easily possible muscle tendon kind of in the groin that if I just push it over that tendon that’s it that’s where the pain is Doc especially when I’m having then abduct their abductor hip passively.
And I am able to Palpate that and stress that area and they’re having pain then I say hey it’s it’s the fact that you’ve got this added injury maybe a little partial tear and maybe more tendinitis but the treatment we’ll be doing offers letting it get better anti-inflammatory is physical therapy stretching and then going from there are rarely these if they’re involving a true tear where it may have lost off of the piece of bone sometimes we go in there talk about fixing these but that’s very rare most of times we’ll let them heal with physical therapy and sometimes it heals in a little bit of stressed out position and then it may actually prevent those injuries in the future if you do get therapy in terms of a pop of of involved an injury. So sometimes I get kids that come in that have pain anywhere from 13 to sixteen years of age they say oh I’m in track I’m doing hurdles. I started running in it and I thought the pain or you know I was doing something long jump and I felt the pain and a lot of times it’s because the kids are still not skeletally mature. They have a growth play that’s inherently weak and sometimes you can get injuries through that area.
So in an adult whereas they would get that tendon a tear and kids usually get an avulsion injury whereas a small piece of that bone rips off the growth plate with those same kind of mechanism and often they’ll have the 10 years per patient in pain with passive stress around that area. You know again for these patients we’re using rest ice anti-inflammatory is protected where bearing so. A lot of times patients come in they’re like oh my gosh you know they told us at the E.R. that we gotta keep this brace on and that we can’t put any weight on it and we got to be on crutches lot times when I see them even if they have a pretty good size policy or watch an injury I always say no it’s OK. You know you can use the crutches, it is tolerated you know and as you start to feel better you can wean off the crutches as long as you’re not stressing it and you’re causing too much pain through this area that you’re OK to away better and do things obviously you know I would not recommend them running or doing other things while this is happening.
And most of these kids they’re pretty resilient you know you give them four to six weeks they come back and they’re ready to go back to sport and they get better.
So here’s a couple of examples. One on the. Right left your left there is a portion of the interview period expired there.
And then the one on the right is the lesser trochanter avulsion there with the iliopsoas attachment.
Next item asked the osteitis pubis. This is one of those very rare things that people talk about but we often really truly see it in clinical practice. It’s an inflammatory process about the pubic surfaces so often patient times patients come and say gosh I slipped him right over kind of the anterior aspect of my groin and it’s painful discomfort and it’s often a diagnosis of. Ruling out other problems. You know a lot of times it can be a little bit confusing and so we’re working on things like sports hernia or adductor tears and strains and a lot of times they’re having just pain over that area.
Let me get an x ray sometimes you can show a little better of that area yet irregularity and widening of that pubic scepticism. That’s how we make diagnosis. Fortunately, these all improve over time without doing anything to special other than some rest and inflammatory in therapy like most of the conditions. The next topic is sports hernias as sportswriters are very confusing because oftentimes there’s a lot of terms out there that are used interchangeably. The way I differentiate just to keep it simple in my head, and I think this is a good technique for everyone, is to have a true hernia. Right which are hernias that come through the inguinal canal through the opening and that’s the stuff that the general surgeons are dealing with, kind of making a turn to the side and diagnosing those hernias. And so that’s a true hernia.
Sports hernias are hernias that occur in athletes. They’re usually involved in Domino hyper extension and thigh abduction activities so such as a soccer player trying to kick a long ball or a field goal kicker or a hockey player. Those are the ones that often get injured with this. And so in terms of the sports hernias there’s actually two different types on the. One is Gilmore’s rowing that was mentioned earlier and that’s more due to the weakening of the Fascia and so the repair for that is a little bit different than a true athletic pubalgia. What’s that. Is really due to the fiber neurotic plate disruption kind of bright at the pubic bone and so they have a slightly different pathology in terms of what’s going on in a slightly different treatment method.
And so from our standpoint as orthopedic surgeons or as primary care it doesn’t really need to differentiate it. I think it’s fine as long as we differentiate between a true hernia. If it’s not a three year that it’s a sports hernia and then we don’t need to worry more about that after that then it’s gonna be up to the surgeons to be able to figure out which one it is and what kind of repair they’re going to need to be doing. And so the exam to find the sports hernia is tenderness over the inguinal region and pain with lots of and really resisted setups.
They should not be having pain with that but often times people with athletic people and also almost going the sports hernias often have pain with it. And again, the important point about the hernia is That traditional hernias occur in the inguinal canal through the opening whereas the sports hernias tend to occur more due to either a tear or a weakening on the canal floor and that’s where something may protrude. And in terms of the athletic privilege it’s really more of a tear at the plate where the abductor muscles and the abdominal muscles attach onto that pubic bone and it’s a disruption in that pubic bone itself. A treatment for this arrest. Ice activities. Therapy. And then depending on what’s going on down the road. It may be a surgery and it may be a surgery to go in there and repeat repair the transversalis fascia. That may be weakened and not completely torn and they may over so that. And then if the fiber neurotic plate is disrupted at the pubic bone, they may do a little adductor recession or either repair or procession of the rectus muscle as well.
Sometimes if they’re having continued pain some surgeons add in a decompression of the general branch of the general femoral nerve to decrease their pain. Here’s one of the examples of a tear in the external oblique muscle so it’s not like a Frank tear but usually you could even just be a weakening where some of that tissue can approach through protrudes through that region where there’s not supposed to be a weakness and then oftentimes what the surgeons will do is put in stitches and there to repair that and reinforce the weakened portion so sometimes I would say there’s not actually a true tear an opening but more of a bonding in that area through that weakness that a lot of times it’s kind of over sawing that region to be able to reinforce that area.
And that’s pretty much it.