The Athletic Hip: Anatomy and Common Injuries Kyle Wilkens MSPAS, PA-C, ATC/L October 8, 2013 Hip Anatomy Bony Femur Ischium Ilium Pubis Sacrum Coccyx Soft Tissue Joints Muscles -Pubic Symphisis Labrum - Sacroiliac Bursae - Coxafemoral Hyaline Cartilage Capsule Ligaments 1
Pelvic Girdle Pelvic Rotation Neutral pelvic rotation is defined as the tip of the coccyx pointing toward the midpoint of the superior aspect of the symphisis pubis Siebenrock KA,Kalbermatten DF, Ganz R. Effect of pelvic inclination on determination of acetabular retroversion on pelvic radiographs. Clin orthop Relat Res, 2003 2
Sacroiliac Joint Bony Anatomy: Coxafemoral Joint Made up femoral head and acetabulum (Ischium, Ilium, and pubic bones) Deep, stable ball and socket joint Three planes of movement: Saggital: Flexion/Extension Frontal: Abduction/Adduction Transverse: Internal/External Rotation 3
Bony Anatomy: Coxafemoral Joint Coxafemoral Joint 4
Bony Anatomy: Femur Hip Active ROM Flexion: 120-130 degrees Extension: 10-20 degrees Abduction: 45 degrees Adduction: 20-30 degrees External Rot: 40-50 degrees Internal Rot: 45 degrees 5
Acetabular Labrum Ligaments/Capsule 6
Intracapsular and capsular ligaments Role of the Capsule Proprioception Structural support è Iliofemoral (resists extension and ER) è Ischiofemoral (constriction) è Pubofemoral (resists extension and ABD) 7
Hip Musculature Hip Musculature: Flexors Psoas Iliacus Rectus femoris Sartorius Pectineus Adductor Longus Adductor brevis Gracilis 8
Hip Musculature: Abduction Tensor fascia latae Gluteus medius Gluteus minimus Sartorius Hip Musculature: Adduction Adductor longus Adductor brevis Adductor magnus (Ischiofemoral portion) Gracililis Pectineus 9
Hip Musculature: Int. Rotation Adductor longus Adductor brevis Adductor magnus Gluteus medius (anterior part) Gluteus minimus (anterior part) Tensor fascia latae Pectineus Gracilis Hip Musculature: Ext. Rotation Gluteus maximus Obturator internus Obturator externus Quadratus femoris Piriformis Gemellus superior Gemellus inferior Sartorius Gluteus medius (posterior part) 10
External Rotators/Extensors Hip Musculature: Extension Biceps femoris Semitendinosus Semimembrinonus Gluteus Maximus Gluteus Medius (posterior part) Adductor magnus( ischiocondylar part) 11
Hip Bursae Nerves 12
Angle of Inclination Angle of Inclination: in the frontal plane, the femoral head normally assumes a 125 degrees with the long axis of the femur Angle of Inclination Coxa valga Angle of inclination of greater than 125 degrees Clinically associated with genu varum or a laterally positioned patellae May lead to early osteoarthritis Coxa vara Angle of inclination of less than 125 degrees Clinically linked to genu valgum or medially positioned patellae Recognized as a cause of cam impingement Tannast et al, AJR:188, June 2007 Millis et al, Orthoedic Jornal at Harvard Medical School, 2004,: 6:84-87 13
Femoral Neck Angles Angle of Torsion Angle of Torsion: In the transverse plane, the relationship between femoral head and femoral shaft, normally an angle of 15 degrees 14
Angle of Torsion Anteversion Torsion angles of greater than 15 degrees Results in internal femoral rotation, squinting patellae, decreased ext. rotation and pigeon toed gait. Retroversion Torsion angles of less than 15 degrees Results in external femoral rotation, lateral patellae, decreased int. rotation and duck-footed position of the feet Associated with cam impingement Squinting Patella 15
New Anatomy Femoral Head Offset Acetabular Retroversion Coxa Profunda/Protrusio Acetabular Overcoverage Femoro- Acetabular Impingement FAI occurs when the ball (head of the femur) does not have its full range of motion within the acetabulum. Impingement itself is the premature and improper collision or impact between the head and/or neck of the femur and the acetabulum leading to a decreased range of joint motion, in addition to pain. FAI is a result of excess bone that has formed around the head and/or neck of the femur (cam-type impingement) and overgrowth of the acetabular rim (pincer-type impingement) or when the socket is angled in such a way that abnormal impact occurs between the femur and the rim of the acetabulum. 16
FAI Associated with cartilage damage, labral tears, hyperlaxity, sports hernias, chronic hip muscular strains and low back pain Most commonly seen in athletes in hockey, soccer, ballet, football, and running due to repetitive flexion, hyperextension and/or external rotation Larson C, Swaringen J, & Morrison G, A Review of Hip Arthroscopy and Its Role in the Management of Adult Hip Pain, The Iowa Orthopaedic Journal, 2005 Pincer Impingement Cause: Focal or general overcoverage Mechanism: Linear contact b/w overcovering rim and head-neck juncture Sex distribution M-F 1:3 Radiographic signs: Cross-over sign, Coxa profunda, posterior wall sign, lateral center edge angle, protrusio acetabuli 17
FAI: Pincer Pincer Impingement 18
Crossover Sign This is defined with the anterior rim line being lateral to the posterior rim in the cranial part of the acetabulum and crossing the latter in the distal part of the acetabulum. Crossover Sign 19
Acetabular Retroversion acetabular retroversion, in which the alignment of the mouth of the acetabulum does not face the normal anterolateral direction, but inclines more posterolaterally. Prominent Posterior Wall Fig. 11 Schematic (left) and radiographic (right) presentations of tooprominent posterior wall (PW) show posterior wall line running laterally to femoral head center in 30-year-old man 20
Cam impingement Cause: Aspherical Head Mechanism: Jamming of the aspherical head portion into acetabulum Sex distribution M-F: 14:1 Radiographic signs: Alpha angle, pistol grip deformity, coxa vara Cam Impingement 21
Acetabular Dysplasia Acetabular Dysplasia is characterized by a shallow and relatively vertical acetabulum, and may predispose to hip instability and degenerative osteoarthritis FAI Related Pathology Chondral damage Labral Tears Hyperlaxity Sports Hernia Chronic strains Lower Back Pain 22
Chondral Damage Pathology: Labral tears, loose bodies, dislocation, FAI, Avascular necrosis, acetabular dysplasia, previous slipped epiphysis Labral Tears Pathology: Degenerative: associated with developmental dysplasia and degenerative OA Structural Tears: Perthes disease, trauma, previous slipped capital epiphysis, and FAI 23
Capsular Laxity Pathology: May be due to repe==ve athle=c movements, hormonal changes, trauma=c injury (sprains), congenital hypermobility leading to early osteoarthri=s Muscular Strains Pathology: Dynamic overload during an eccentric contraction or overstretching. Often associated with FAI due to changes in joint mechanics. Most commonly adductors, hamstrings, and hip flexors are involved Starkey, C & Ryan J, Evaluation of Orthopedic and Athletic Injuries, 2 nd ed. 24
Sports Hernia/ Athletic Pubalgia Pathology: Thought to result from simulataneous trunk hyperextension and thigh hyperabduction leading to shearing forces across the pubis symphysis. Athletes with muscular imbalance between strong thigh muscles and weaker abdominal muscles may have higher shearing forces across the symphysis and may be more prone to injury. Tibor, L & Sekiya, J Current Concepts Diffential Diagnosis of Pain Around the Hip Joint, Arthroscopy: The Journal of Arthroscopic and Related Surgery, 2008 Piriformis Syndrome Pathology: May be due to anatomic variations in either the muscle or nerve, piriformis hypertrophy, or spasm 25
SI Joint Pain Pathology: Related to lower extremity injury including the hip due to changes in gait. May also be related to degenerative osteoarthritis due to repetitive motions of sport. More Hip Pathology Snapping Hip Bursitis AVN Femoral Neck Stress Fracture Avulsion Fractures Hip Pointer (Iliac Crest Contusion) 26
Snapping Hips Intraarticular due to Loose bodies Labral pathology Snapping Hips Extraarticular due to Iliopsoas over iliopectineal eminence, femoral head, or lesser trochanter IT Band or gluteus medius over greater trochanter 27
ITB/Greater Trochanteric Bursitis Pathology: thickened IT Band or glute maximus over greater trochanter resulting in repetitive friction b/w greater trochanter and ITB Women prone due to wider pelvis Avascular Necrosis AVN is the death of cells secondary to a lack of adequate blood supply In athletes, most commonly the result of trauma 28
Femoral Neck Stress Fracture Epidemiology Endurance athletes, female athlete triad (eating disorder, amenorrhea, osteoporosis) Pathophysiology Increased volume or repetitive WB activity Avulsion Fractures Epidemiology Occurs most commonly in adolescent athletes Pathophysiology Unexpected, explosive muscle contraction Fractures occur at apophyses 29
Thank You 30