Overview. Overview. Introduction. Introduction Anatomy History Examination Common Disorders. Introduction Anatomy History Examination Common Disorders

Transcription

1 Common Hip Disorders in Figure Skaters 14 th Annual Meeting of Sports Medicine and Science in Figure Skating January 25, :15-8:45am Robert J. Dimeff, MD Medical Director of Sports Medicine Overview Introduction Anatomy History Common Disorders Overview Introduction Anatomy History Common Disorders Introduction 5% of sport injuries are hip and groin Side-to side, kicking, and twisting Hockey, soccer, high jump, hurdles, xc ski Likely higher in figure skaters Diagnosis unclear in 30% of cases Complex anatomy and coexisting injuries 1

2 Overview Introduction Anatomy History Common Disorders Anatomy Ball and socket joint Highly constrained Inherently stable due to bony architecture Increased constraint comes at the expense of range of motion Anatomy Acetabulum Hemispherical shape 3 Innominate bones Cartilage thickest superiorly Hip Joint 3 degrees of rotational freedom Femoral head cartilage thickest centrally Smooth rotation aided by synovial fluid Anatomy Capsule Significant restraint Thick ligamentous complex: iliofemoral band (Y ligament of Bigelow), ischiofemoral ligament, ligamentum teres, transverse acetabular ligament Labrum Fibrocartilagenous lip Contributes to shape, depth and stability 2

3 Anatomy Femur o neck-shaft angle o femoral anteversion o 40 in children Head orientated cephalad, medial, anterior Hip Flexors Iliopsoas Sartorius 2 joint muscles Femoral nerve Hip Extensors Adductors Gluteus Maximus Inferior gluteal n Semitendinosus Semimembranosus Biceps Femoris Tibial br sciatic Short head-peroneal br. Pectineus Femoral Nerve Gracilis Adductor brevis Adductor longus Adductor magnus Obturator externus Obturator nerve 3

4 Adductors Abductors Pectineus Femoral Nerve Gracilis Adductor brevis Adductor longus Adductor magnus Obturator externus Obturator nerve External Rotators Overview Piriformis Superior gemellus Obterator internus n to O.I. Inferior gemellus Quadratus femoris n to Q.F. Gluteus medius Gluteus minimus Tensor fascia lata IT band Superior gluteal n Introduction Anatomy History Common Disorders 4

5 History Chief complaint Date of injury Onset-acute or chronic Mechanism of injury Pop or snap at time of injury (felt or heard) Swelling-onset, location, recurrence Discoloration History Pain: nature, location, radiation Jumps, spins, moves; timing Exacerbating and relieving factors Instability, giving way Catching, locking Skates Training schedule History Ice surface Exercise FID Night pain Functional ability History Previous injury and RX Orthopaedic problems Medical problems Medication/supplement Diet Sun exposure RX and outcome 5

6 Overview Introduction Anatomy History Common Disorders Body habitus Lumbar spine Gait Leg length Standing Supine Palpation Localize pain Galeazzi sign ROM Comparison Flexion-120 o Extension-15 o IR-35 o ER-45 o ABD-40 o ADD-30 o Muscle testing to assess if a particular muscle group is the source of pain Resisted hip flexion, extension, adduction, abduction, external/internal rotation 6

7 FABER Test (Patrick s Test) Patient lies supine Hip Flexed, ABducted, and Ext Rotated Lower the leg toward the table Positive test elicits anterior or posterior pain indicating hip or sacroiliac joint involvement 88% sensitive for intra-articular pathology in the athletic population Trendelenburg Test Stands on affected leg-weak glut medius Ober s Test Lie on side with hip and knees flexed Upper leg is passively extended and lowered to the table Lateral hip pain or limited flexibility indicates ITB syndrome Ober s Test 7

8 Noble Compression Test Cross affected leg Palpate ITB above lateral joint Thomas Test Patient lies supine Contralateral hip is flexed Symptomatic hip is moved from full flexion to full extension Deep click suggestive of a labral tear Lack of full extension suggests ilipsoas contracture or bursitis Thomas Test Hamstring Tightness Tripod sign SLR 8

9 Ely s test Rectus femoris tightness Femoral n stretch Pyriformis Gluteal tenderness Flexed, IR, and adduction Hip labral tear Hip flexion, axial load, IR, adduction Overview Introduction Anatomy History Common Disorders 9

10 Common Disorders Contusion Acute Muscle Strains Sports Hernia ITB Tendonitis Snapping Hip Contusions Avulsion Fractures Most common hip injury RICE, analgesics Modalities, aspiration Stress Fractures Labral Tear Femoral Acetabular Impingement Acute Muscle Strains Common hip injury Hip Flexor, Adductor Longus, Pyriformis Eccentric mechanism Compression Muscle imbalance, core strength, technique Acute Muscle Strains Local tenderness Pain with passive stretch and resisted action Sciatic symptoms-sitting Imaging studies RICE, rehab, nsaids (?) Modalities, ESWT Injections-cortisone, PRP 10

11 Acute Muscle Strains Local tenderness Pain with passive stretch and resisted action Sciatic symptoms-sitting Imaging studies RICE, rehab, nsaids (?) Modalities, ESWT Injections-cortisone, PRP Sports Hernia Chronic, exertional pain in the groin and lower abdomen in athletes Hyperextension and hyperabduction Muscle imbalance Strong adductors Weak lower abdomen Pelvic shear forces Sports Hernia Unilateral groin pain Occasionally bilateral Pain during exercise, coughing, sneezing Tenderness over pubic tubercle, conjoined tendon, mid-inguinal region Resisted sit-ups and adduction Sports Hernia IO, EO, conjoint tendon Transversalis thinning Ilioinguinal n. entrapment Imaging Treatment 11

12 ITB Tendonitis/Bursitis Traumatic vs strain Swelling Tenderness Pain reproduction Treatment Prevention Snapping Hip External-IT band snaps over the greater trochanter from hip extension to flexion due to thickening of the posterior aspect of the IT band Internal-Iliopsoas catches over the pelvic brim or femoral head as hip moves from flexion, abduction & ER to extension Tenderness, reproducing snapping Snapping Hip Imaging: mri vs msk u/s Treatment: rest, ice, analgesics, activity modification, stretching, modalities, injections, ESWT, bursectomy, lengthening, or tenotomy Avulsions Fractures Sudden forceful concentric or eccentric contraction of the muscle attaching to apophysis Adolescent athletes (11-17) Swelling, loss of motion Point tenderness Pain with resisted motion 12

13 Avulsions Fractures A - Iliac crest (I/E O) B - ASIS (sartorius + TFL) C - AIIS (rectus femoris) D - GT (gluteus medius) E - LT (iliopsoas) F - Ischial tuberosity (hamstrings) G - Pubic symphisis (adductors and gracilis) Avulsions Fractures RICE, analgesics Rehab, ESWT > 3cm displacement Painful nonunions Stress Fractures Pelvis and Hip Tenderness Pain with rotation Imaging Treatment 25 OH Vit D level Labral Tear Post traumatic hip/groin pain Months to years Painful click Relatively normal exam Imaging Relative rest, ice, analgesics, rehab, injection Surgery Predisposition to DJD 13

14 Femoral Acetabular Impingement FAI Groin/knee pain Intermittent, sitting Limited ROM Impingement testing Labral Tears Femoral Acetabular Impingement Imaging Cam type Pincer type Treatment Medical Surgical Arthritis Thank You 14