Hip Tendinopathy. Outline. Tendon Anatomy 6/6/2011. Tendinopathy Hip adductor Iliopsoas Gluteus medius / minimus Hamstring New treatments

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1 Hip Tendinopathy Kelly C. McInnis, DO Massachusetts General Hospital Sports Medicine Center Physical Medicine and Rehabilitation Outline Tendinopathy Hip adductor Iliopsoas Gluteus medius / minimus Hamstring New treatments Tendon Anatomy Collagen bundles Extracellular matrix Tenocytes Epitenon Paratenon 1

2 Enthesis Chondral-apophyseal Ends of long bones Fibrocartilaginous Periosteal-diaphyseal l Shafts Fibrous Direct attachment to bone or periosteum Benjamin M et al. J Anat April Tendinopathy Acute injury Tendonitis Acute inflammation of tendon Tendinosis Degeneration, microtearing Microscopic Near absence of inflammatory cells Tenocyte death, extracellular matrix degeneration, neovascluarity, hypercellularity, ingrowth of nociceptive nerves Tendinosis Etiology Vascular compromise Watershed zones Repetitive microtrauma Matrix degradation; failure to regulate matrix metalloproteinase activities Aging 2

3 Mechanical Loading Mechanical Loading Khan KJM et al. Research Update - Histopathology of Common Tendinopathies Update & Implications for Clinical Management Sports Med (1999) Microscopic Macroscopic 3

4 Imaging Hip Tendinopathy in the Athlete Adductor Iliopsoas Gluteus medius Hamstring Adductor Tendinopathy Anatomy Adductor longus, brevis, gracilis Adductor longus Origin 37.9% tendon, 62.1% mm E.J. Strauss et al. Am J Sports Med Poorly vascularized, richly innervated at transitional zone Medial fibers attach to symphyseal capsule, intraarticular disk 15-30% combined w/ rectus abdominus injury Precursor to osteitis pubis 4

5 Adductor Injury Groin pain: 5-18% of athletic injuries Cutting, kicking Soccer, hockey AL load at transition from HE to HF Risk factors Weakness, inflexibility, imbalance Chronic adductor tendinopathy Repetitive strain, overuse Failed management of acute injury Groin or medial thigh pain, stiffness Tenderness to palpation Pain, weakness w/ resistance Adductor Tendinosis Schilders E. et.al. J Bone Joint Surg 2009:91:

6 Management Conservative Relative rest Strengthening common adductor-rectus axis Pelvic stability / balance Holmich et al. Lancet Randomized to active vs passive PT Treatment 8-12 wks Active group: 79% return to athletic activity w/o residual groin pain RTP up to 6 mo; mean of 18.5 weeks Adductor-Related Groin Pain in Competitive Athletes. Role of the Adductor Enthesis, Magnetic Resonance Imaging, and Entheseal Pubic Cleft Injections Schilders E. et.al. J Bone Joint Surg Case series: 24 failed conservative care. Group 1 (7) normal MRI Group 2 (17) MRI enthesopathy All corticosteroid + LA injection Results: 5 min: All pain resolution 1 year: Group 1, No recurrence Group 2, recurrence mean 5 wks (1-16 wks) MRI may predict post-injection outcome Fig. 2 Oblique axial line diagram depicting adductor longus enthesopathy Exercise program for prevention of groin pain in football players: a clusterrandomized trial. Design 44 clubs; 977 players Exercise group: 6 specific pelvic exercises Control group Results 31% risk reduction; not significant Previous injury highest risk Holmich et al. Scand J Med Sci Sports

7 Adductor tenotomy: its role in the management of sports-related chronic groin pain. Atkinson et al. Arch Orthop Trauma Surg Percutaneous adductor tenotomy 48 (68 groins) failed conservative tx Results 60% >= pre-injury Tegner scores 18.5 weeks mean RTP 73% rated outcome as excellent or very satisfactory Complications: scrotal hematoma (3), infection (1) Iliopsoas Tendon 7

8 Internal Snapping Hip Anatomy Neutral tendon position Iliopsoas bursa Communication w/ hip capsule 15% Function Hip flexion, erect posture Internal snapping hip Tenderness Risk for labral tear Ultrasonography Dynamic evaluation Color Doppler Contralateral exam Infrequent tendinopathy w/ snapping hip Pelsser et al Guided injection Blankenbaker D. Skeletal Radiol Treatment Physical Therapy NSAIDs, activity modification Injection Surgery Open lengthening Endoscopic release 8

9 Gluteus Medius / Minimus Tendinopathy Anatomy Hip rotator cuff 4 facets Ant, post, superopost, lat Tendon attachments Abductors: Gluteus med, min External Rotators: piriformis, obturator externis / internus 3 bursa Sub glut max Sub glut med Sub glut min Pfirrmann et al. Radiology Trochanter Anatomy W.J. Robertson et al. Anatomy and dimensions of the gluteus medius tendon insertion. Arthroscopy Peritrochanteric Pain Female 4:1 Increasing incidence in athletes Wider pelvis, femoral anteversion Lateral hip pain, buttock pain Former thinking Trochanteric Bursitis Recent imaging studies reveal Gluteus medius / min tendinopathy Less frequent bursitis 9

10 Gluteus Medius / Minimus Tendinopathy Insidious onset Degenerative, progressive tears Interstitial partial tears most common ¼ middle-aged women, 1/10 men Tender at trochanter Pain w/ sidelying Pain w/ resisted abduction, passive adduction Dynamic Testing Lequesne et al. Gluteal tendinopathy in refractory greater trochanter pain syndrome: diagnostic value of two clinical Arthritis Rheum Silva F. et al. Journal of Clinical Rheumatology. 14(2); April Management Conservative Activity modification Role of NSAIDs, corticosteroid injxn Physical therapy Evaluate kinetic chain Abductor / ER Strengthening ITB, TFL stretching 10

11 Ultrasound guided injection Management Surgical Refractory cases Open repair Kagan et al. JBJS Case series (7) All resolution of pain Endoscopic repair glut med Voos et al. AJSM Case series (10) Resolution of pain, full strength out to 25 mo Sports specific activity at 4 mo Hamstring Tendinopathy Anatomy Biceps femoris Extensive distal insertion Dual innervation MTJ spans entire length Semitendinosus Semimembranosus Koulouris G, Connell D Radiographics 2005;25: by Radiological Society of North America 11

12 Hamstring Injury Most commonly injured mm in sport Running, jumping, dancers Eccentric ctx at terminal swing, HF / KE Avulsion vs strain Insertion, PMTJ 83% proximal injury involve semimembranosus Askling CM et al. AJSM Significant contributor to morbidity Proximal Hamstring Tendinopathy Hamstring syndrome Gradual onset or mild acute event Overstretching, mild strain Deep buttock pain, thigh pain Decreased sitting tolerance Worsened by cont exercise Ischial tuberosity pain w/ stretch or resistance Proximal Hamstring Tendinopathy 29 y.o. male Olympic marathon runner 12

13 Proximal Hamstring Tendinopathy Conservative Stretching Soft tissue mobilization Progressive eccentric strengthening, core stabilizing Improve H:Q ratio RTP can take several months Cochrane Database Syst Rev Limited evidence that rate of recovery increased w/ stretching program. Consideration to spine, SIJ, pelvic alignment and control when managing injuries. Lempainen L et. al. AJSM Case series, 90 athletes Average 21 months of symptoms Semimembranosus tenotomy, sciatic nerve exploration Mean f/u 48 months 89% excellent or good result and were able to return to the same level of sporting activity at mean of 5 month 1 DVT, 1 fistula, 2 hyperesthesia that resolved Biopsy confirmed tendinosis in all specimens Tendinosis New Treatments; Basic Principles Hypovascularity Transdermal Nitroglycerin Murrell GA. Using nitric oxide to treat tendinopathy. BJSM Extracorporeal shock wave therapy Matrix degradation Platelet Rich Plasma injection Stem cell injection / graft Adalimumab (TNF alpha blocker) Anakinra (IL 1 antagonist) Tropisetron (sertonin 2 receptor antagonist) 13

14 Platelet Rich Plasma Injection Biologic tool Safe Delivered as treatment within 30 min Available at point of care Growth factors delivered directly to local injury Rapid vascularization of the healing tissue Important Outstanding Questions Effect on acute injury vs tendinosis? Timing of injection (s)? Risk of increasing inflammation? Effect of ph on cytokine release? Technique? Imaging guidance and follow up? Macroscopic outcome measures? Tensile strength of tendon? Effect on nociception? Rehabilitation? Thank You 14