Female Athlete Hip Injuries: Exploring the CORE of Patterns and Prevention Kelly C. McInnis DO Irene Davis, PhD, PT, FAPTA, FACSM, FASB David Nolan, PT, DPT, MS, OCS, SCS, CSCS Your name and credentials Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA Massachusetts General Hospital Sports Medicine
Outline Gender differences Hip Injuries Labral tear Iliopsoas tendinopathy Gluteal tendinopathy Stress fracture Gluteal Injuries Ischiofemoral impingement
Pelvic Structural Differences Male Narrower, heart-shaped inlet Narrower sciatic notch Muscular impression more distinct Female Open, circular inlet, less depth Anterior pelvic tilt Broader sciatic notch Bones more slender; muscular impressions less distinct
Pelvic Structural Differences Female Greater iliac flare Wider pubic angle Wider ischial tuberosity Pubic symphysis shorter Wider fibrocartilage disc
Hip Joint Female Greater risk of dysplasia Femoral, acetabular anteversion Smaller femoral head Possible increased contact pressures Greater trochanteric distance side to side Coxa vara Femoral neck architecture
Dynamic Alignment
Landing Mechanics
Female Athlete Injuries Knee Anterior Cruciate Ligament Patellofemoral disorders Iliotibial Band Syndrome Hip and Pelvic Acetabular labral tear Iliopsoas tendinopathy Gluteus medius / minimus tendinopathy Trochanteric bursitis Stress fracture Osteitis Pubis Sacroiliac Joint Dysfunction Piriformis pain Ischiofemoral impingement Proximal hamstring injury
Hip Pain Intra-articular Extra-articular Referred Labral Trauma Hypermobility Impingement Dysplasia Degenerative Chondral Osteoarthritis Lateral Impact Dislocation Subluxation AVN Synovial Chondromatosis Capsular Capsular Laxity Iliofemoral lig. attenuation Adhesive Capsulitis Synovitis Ligamentum teres injury Muscle Tendon Bursa Ligament Sports Hernia Nerve Bone Lumbar Radiculopathy Sacroiliac joint Visceral OB / GYN
Hip Pain Intra-articular Extra-articular Clinical Assessment Imaging Diagnostic Injection
Labrum Function Extension of Bony Acetabulum Shock absorber Suction Seal Weber 1837, Takechi et al. 1982 Tear Loss of Suction Seal Synovial fluid leak Decrease hydrostatic pressure Increase cartilage compression Relative instability
Labrum Blood supply Mostly avascular May be peripheral blood vessels? Healing potential Nerve supply Obturator nerve Branch of nerve to quadratus femoris
Histology of pain receptors Distribution on labrum, ligamentum teres and capsule Nociceptin, Substance P, Neuropeptide Y Highest concentration anterosuperior at chondrolabral junction Haversath M et al. 2013 13
Labral Tear Active young adults Women > men Dance, gymnastics, soccer, runners Hypermobility; Beighton score Females more commonly atraumatic Abnormal joint morphology Dysplasia, instability, internal snapping hip, FAI Females milder FAI but more symptomatic Females worse self-reported outcomes post op Neuromuscular risk factors? Precursor to OA
Do all Labral Tears Cause Pain? 70 asymptomatic patients, mean age 26, 67% female 3T MRI Labral tears in 38% 45 patients, mean age 38 Labral tears in 70% Military Labral tears in 86% College and Pro Ice Hockey Labral tears in 56% and 86%
Diagnostic Accuracy of Clinical Assessment, MRI, MRA, and Intra-Articular Injection in Hip Arthroscopy Patients. AJSM. Byrd and Jones. 2004. Intra-Articular Injection 7 % false-negative 2 % false-positive 90 % accurate Most reliable indicator of intra-articular abnormality
Nonoperative Treatment Relative rest, NSAID trial Role of Focused PT Balance of hip / core strength, flexibility Encourage posterior pelvic tilt Gluteus medius Neuromuscular modifications Injection Unclear potential for labral healing Recurrence of symptoms Close follow up; re-imaging
Iliopsoas Tendon Directly anterior to the anterosuperior capsulolabral complex at 2 o oclock
Iliopsoas Tendon Anatomy Neutral tendon position Iliopsoas bursa Communication w/ hip capsule 15% Function Hip flexion, erect posture Internal snapping hip 10% population; 50% in adolescent ballet dancers; hypermobility 50% + intraarticular pathology Risk for labral tear
Examination Ilizaliturri and Camacho-Galindo. Sports Med Arthrosc Rev. 2010.
Ultrasonography Dynamic evaluation Color Doppler Contralateral exam Infrequent tendinopathy w/ snapping hip Pelsser et al. 2001. Guided injection Blankenbaker D. Skeletal Radiol. 2006
Treatment Physical Therapy Balance of Hip extensors / flexors NSAIDs, activity modification Injection Recession of Iliopsoas Pelvic Brim Transcapsular release (50/50) Lesser trochanter (60% tendon/40% muscle) Mixed outcomes Blomberg JR et al. AJSM. 2011
Femoral Neck Stress Fracture Diagnosis frequently delayed Compression side WBing restriction Conservative care Tension side High risk nonunion, displacement Surgical fixation
FNSF 25 Injuries; 95.2% were runners Averaged 25.6 mi/wk (range 10-75) 47.6% had a prior stress fracture Presentation Anterior or anterolateral pain +/- groin radiation Exam Low BMD 36% Vit D insufficient (< 32) in 17% Prognosis Grade 4: 20 wks to return to running Females 88% Ramey L and McInnis KC. AMSSM. 2015.
Gluteus Medius Strength Strain gauge studies Neutralizes tensile stress through femoral neck Key to hip biomechanics Need strong, reactive glut med, resistant to fatigue May be modifiable risk factor for femoral neck stress fracture; intraarticular pathology Egol et al. CORR. 1998.
Pubic Stress Fracture 1-7% of all stress fractures Groin pain; often misdiagnosed Medial portion of pubic ramus or jxn b/t inferior pubic ramus and ischial ramus May be adductor magnus load as hip is extended Mixed training in military; women increased stride length Distance runners
Iliac Stress Fracture 49F marathon runner w/hip and groin pain 3 mon prior: TAH and bowel resection + hop test, SIJ provocative tests Tenderness over iliac crest MRI Stress fracture at mid-body ilium, edema in iliacus and glut min NWBing 4 wks, PT, RTR 3 months BMD normal, Ca/Vit D normal Very rare, usually insufficiency fractures Few case reports in runners
Lateral Hip Pain
Trochanter Anatomy Hip rotator cuff 4 facets Tendon attachments Gluteus medius, minimus piriformis, obturator externis / internus 3 bursa Sub glut max Sub glut med Sub glut min Pfirrmann et al. Radiology. 2001.
Biomechanics Rotator cuff of hip External rotators Abductors Joint compression Neumann DA. JOSPT 2010
Peritrochanteric Pain Female 4:1 Increasing in athletes Wider pelvis, femoral anteversion Weak gluteals Lateral hip pain Former thinking Trochanteric bursitis Recent imaging studies Gluteus medius / min tendinopathy Less frequent bursitis
Gluteus Medius / Minimus Tendinopathy Insidious onset Degenerative, progressive tears Interstitial partial tears most common ¼ middle-aged women, 1/10 men Tenderness 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. 2008. Silva F. et al. Journal of Clinical Rheumatology. 14(2); April 2008.
Treatment Individualized Program Activity modification NSAID trial, topical Physical Therapy Abductor strengthening Isolated from TFL, Iliopsoas Core, pelvic stabilization Motor retraining Role of injection
8 Level IV studies reviewed 90% women; average symptom 2yrs Gluteus medius partial tears most common Both medius and minimus occurred 1/3 of pts Good to excellent functional outcomes and pain reduction Complications rates low 13% open (DVT, PE, infection, 1 fracture) 3% endoscopic (superficial infection) Risk of retear 9% in open repair; none reported in endoscopic repair Voos et al. AJSM. 2009.
Case 32 F runner glut pain Sitting intolerance Exam Gastroc asymmetry Absent achilles Eval MRI spine, pelvis EMG U/S Treatment
Ischiofemoral Impingement Groin, buttock pain Possible sciatic neuralgia IFS narrows w hip add/er Risks Less trochanter fractures Intertroch osteotomy OA w superomed migration Prox hamstring enthesopathy Bone lesions PT, guided injection, surgery
Summary Structure, characteristic movement patterns and hypermobility contribute to several common female athlete hip and pelvic injuries Importance of kinetic chain, neuromuscular control about the pelvis, motor retraining Gluts are KEY Prevention best treatment
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