Diagnosis and Management of Athlete's Hip

Educational Objectives

The goal of this program is to improve management of hip pain. After hearing and assimilating this program, the clinician will be better able to:

1. Relate the location of hip pain to its probable causes.
2. Identify femoral acetabular impingement with passive motion tests.
3. Use imaging to diagnose the cause of hip pain.

Summary

Common Hip Problems (by Location)

Anterior hip pain: intra-articular pathology (eg, femoral acetabular impingement [FAI], labral tears, chondral lesions, chondromalacia) causes groin pain; x-rays may rule out arthritis; the snapping of the iliopsoas tendon over the front of the hip is the cause of internal snapping hip syndrome

Lateral hip pain: greater trochanteric bursitis may cause pain; external snapping hip syndrome involves the iliotibial band; the gluteus medius and minimus (ie, the rotator cuff of the hip) may tear

Posterior hip pain (PHP): posterior labral tears often are seen in cases of trauma (eg, injuries caused by impact with the dashboard in a motor vehicle accident, tackles from behind in football); extra-articular PHP is caused by, eg, hamstring tendinitis or tears, sacroiliitis, greater trochanteric bursitis, piriformis syndrome, sciatica; intra-articular PHP is less common than extra-articular

Bone: femoral head or neck issues often present as groin pain; avascular necrosis of the femoral head is associated with sickle cell anemia, or may have idiopathic causes (eg, oral steroids, autoimmune diseases); femoral neck stress fractures are common in runners; young runners have open growth plates; iliac crest apophysitis or avulsion fractures of the iliac crest may occur because of a tight sartorius

Other causes of hip pain: pubalgia is a stress injury of the pubic symphysis and may appear similar to stress fracture of the symphysis; sports hernia are felt more proximally than typical groin pain, and occur due to weakening of the muscles and fascia of the abdominal wall; intrapubic pathology (eg, ovarian cysts, pelvic floor weakness) may be seen on magnetic resonance imaging (MRI)

FAI: the most common cause of hip pain in active adults in the nonarthritic age group; FAI is associated with repetitive hip flexion; patients with labral tears may develop mechanical symptoms, eg, clicking, snapping, catching, locking, popping; FAI may be indicated by patients making the “C sign”, ie, laterally gripping the hip with a cupped hand

Anatomy of the hip joint: the majority of intraarticular hip injuries occur in the anterior superior quadrant; key structures in the quadrant include the femoral neck, acetabulum labrum, anterior hip capsule, and the iliopsoas; all 4 structures in combination may produce pain in patients with FAI; structures that show as white on MRIs may be damaged (black is healthy)

Causes of FAI: hip flexion which is repetitive and excessive in women with normal hip anatomy and abnormal hip motion, or in men with abnormal hip anatomy (ie, cam lesions) and normal hip motion; excessive flexibility in patients with normal hip anatomy may produce FAI; tight anterior structures (eg, flexors, adductors) and relatively weaker posterior structures (eg, extensors, abductors), which act to decelerate the motion of the hips, may cause FAI

Types of FAI: cam-type, pincer-type, and mixed FAI are seen; cam is the more common bony abnormality and more common in men; pincer is a prominence of the acetabular rim; a cam lesion occurs when the femoral neck bumps up into the labrum and separates it from the acetabular bone, which causes tears of the labrum; cartilage damage may lead to arthritic changes; repetitive hip flexion may cause tightening of the iliopsoas, which prevents gliding over the hip joint during hip rotation; the hip capsule is impinged between the iliopsoas tendon and the hip joint as the iliopsoas snaps over the hip (ie, bursitis); stretching exercises for the hip flexor may increase flexibility and lessen the impingement; surgical lengthening also may be an effective treatment

Other snapping hip syndromes: iliotibial band (ITB) syndrome may be caused from a contusion from trauma or overuse; the tight ITB snaps over the greater trochanter; steroid injections may be effective; surgical treatment involves decompression or removing the tight portion of the ITB

Focused Hip Examination

Hip flexion examination: may reproduce groin pain in cases of impingement; the FADDIR test (flexion, adduction, internal rotation) is used to examine FAI; the FABER test (flexion, abduction, and external rotation) is used to check for the snapping of the iliopsoas tendon (ie, snapping hip syndrome) over the front of the hip; look for snapping or reproduction of the familiar groin pain; range of motion (ROM) also should be checked

Test for contractures: anterior contracture is measured by the knee-to-table height test; measure the height of the knee to the table and compare it to the opposite hip; simple resistance of the straight leg raise may reproduce hip and groin pain; greater trochanter bursitis may be assessed by turning the patient on their side and placing the thumb over the greater trochanter to feel for the snapping hip; Ober's test — the hip is extended and knee flexed to test if the patient is able to reach the table with their knee; grade 1 tightness is indicated by the knee reaching halfway between the hip and the table; grade 2 tightness is indicated by the knee reaching level with the hip; grade 3 tightness is indicated by the knee reaching above the level of the hip; a patient able to bring their knee to the table is graded as normal

Iliopsoas pathology: Stinchfield's test — a resisted straight leg raise with the foot pointing forward in neutral; externally rotating the hip during a resisted straight leg, with the foot in external rotation, is a modified Stinchfield's test; the iliopsoas is isolated during the movement; greater pain and weakness with the foot in external rotation on a straight leg raise indicates the iliopsoas may be inflamed, injured, or snapped

X-rays: joint space narrowing and symmetry between the two joints may be assessed with an x-ray of the pelvis from the anterior-posterior view while standing; recommended for all patients; a frog leg lateral view of the involved hip may show, eg, roundness of the hip, cam lesions, narrowing of the hip joint, loose bodies, bone spurs, pincer lesions

Radiographic signs: an α angle <50° indicates that cam impingement has developed into a pistol-grip deformity; an α angle >50° may indicate cam lesions and impingement; coxa profunda is an abnormally deep socket, which is deepened by growth of the rim of the acetabulum; a crossover sign on the rim of the acetabulum on x-ray indicates a pincer lesion has formed

Conservative treatment: an FAI caused by excessive flexion, adduction, and internal rotation, may be treated by stretching the anterior structures and improving their flexibility; strengthening the posterior structures (eg, hip extensors, external rotators, abductors) complements stretching of anterior structures; Martin et al (1999) found that arthroscopy was more effective in patients >40 yr of age compared with physical therapy

Traditional treatment: non-steroidal anti-inflammatory drugs (NSAIDs) may be used to decrease inflammation; ice, therapeutic ultrasonography, corticosteroids (injection or oral) may be used to treat pain from inflammation of the hip capsule

Surgical treatment: the labrum may be repaired arthroscopically; associated chondromalacia or chondral injuries may be addressed during the surgery; the bone is decompressed to relieve pressure in men with cam lesions; the hip capsule may be tightened to address capsular laxity or increased ROM in women with labral tears; the iliopsoas tendon may be released or lengthened in women with inflammation or a positive snapping hip test; sutures are placed around the labrum to re-attach it to the hip joint socket; cam lesions are removed from the neck of the femur; a meta-analysis by Minkara et al (2019) found that 88% of the patients with hip labral repairs were able to return to sports; a complication rate of 1.7% and a reoperation rate of 5.5% was found

Readings

Agten CA, Sutter R, Buck FM, et al. Hip imaging in athletes: sports imaging series. Radiology. 2016 Aug; 280(2):351-69. doi: 10.1148/radiol.2016151348; Boric I, Isaac A, Dalili D, et al. Imaging of articular and extra-articular sports injuries of the hip. Semin Musculoskelet Radiol. 2019 Jun; 23(3):e17-e36. doi: 10.1055/s-0039-1688696. Epub 2019 Jun 4; DiSilvestro K, Quinn M, Tabaddor RR. A clinician's guide to femoacetabular impingement in athletes. R I Med J (2013). 2020 Sep 1; 103(7):41-48; Hegazi TM, Belair JA, McCarthy EJ, et al. Sports injuries about the hip: What the radiologist should know. Radiographics. 2016 Oct; 36(6):1717-1745. doi: 10.1148/rg.2016160012; Jackson TJ, Estess AA, Adamson GJ. Supine and standing AP pelvis radiographs in the evaluation of pincer femoroacetabular impingement. Clin Orthop Relat Res. 2016;474(7):1692-1696. doi:10.1007/s11999-016-4766-7; Jacobson JA, Bedi A, Sekiya JK, et al. Evaluation of the painful athletic hip: imaging options and imaging-guided injections. AJR Am J Roentgenol. 2012 Sep; 199(3):516-24. doi: 10.2214/AJR.12.8992; Minkara AA, Westermann RW, Rosneck J, et al. Systematic review and meta-analysis of outcomes after hip arthroscopy in femoroacetabular impingement. Am J Sports Med. 2019 Feb; 47(2):488-500. doi: 10.1177/0363546517749475. Epub 2018 Jan 26; Pun S, Kumar D, Lane NE. Femoroacetabular impingement. Arthritis Rheumatol. 2015;67(1):17-27. doi:10.1002/art.38887; Shanmugaraj A, Shell JR, Horner NS, et al. How useful is the flexion-adduction-internal rotation test for diagnosing femoroacetabular impingement: a systematic review. Clin J Sport Med. 2020;30(1):76-82. doi:10.1097/JSM.0000000000000575; Yoo JH, Hwang JH, Chang JD, Oh JB. Management of traumatic labral tear in acetabular fractures with posterior wall component. Orthop Traumatol Surg Res. 2014;100(2):187-192. doi:10.1016/j.otsr.2013.12.016; Willett GM, Keim SA, Shostrom VK, Lomneth CS. An Anatomic investigation of the Ober test. Am J Sports Med. 2016;44(3):696-701. doi:10.1177/0363546515621762.

Disclosures

For this program, the following relevant financial relationships were disclosed and mitigated to ensure that no commercial bias has been inserted into this content: Dr. Ho has been a consultant for Zimmer Biomet, received a fellowship grant from Smith & Nephew, and has been a shareholder at BandGrip. Members of the planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Ho was recorded at the 27th Annual Primary Care Orthopedic Course, on June 8, 2022, presented by the University of Chicago Pritzker School of Medicine. For information on upcoming CME activities from this presenter, please visit cme.uchicago.edu. Audio Digest thanks the speakers and the University of Chicago Pritzker School of Medicine for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 1.00 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 1.00 CE contact hours.

Lecture ID:

OR452101

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.