Download Hip Pathology in the Adolescent athlete

Hip Pathology in the Adolescent athlete
Dr.EMAD KARIM
This article will review the more common
causes of hip and groin pain in the
adolescent athlete,
as well as advances in diagnostic and
therapeutic interventions.
Risk factors to adolescent hip pathology include:
musculoskeletal balance
open physes and growing
Physical examination
Patients with intra-articular hip pain place a hand in the
shape of a C around the hip.
Groin pain often has an intraarticular etiology lateral hip
pain is usually associated with extraarticular causes.
Isolated posterior buttock pain is often related to lumbar
and sacroiliac joint dysfunction.
Physical examination of the hip includes The four
layers : osseous, cartilaginous, muscular, and
neural.
The examination includes evaluation of gait and
physical tests in the standing, supine, lateral, and
prone positions.
Trendelenburg patterns manifest as lateral trunk
flexion while shifting weight over the stance leg.
The (FABER) test is used to diagnose injuries to the
labrum.
The anterior impingement test is performed with the
patient in the supine position; the hip is flexed to 90°,
and a dynamic assessment of the hip joint is performed
with flexion,adduction, and internal rotation.
The scour test is performed with the patient in the
supine position. The hip is brought to 90° of flexion and
abducted, followed by compression with internal and
external rotation.
Acetabular Labral Tears Injury is a source of hip pain.
5 Injury may occur as a result of hypermobility or
repetitive mechanical stresses with excessive flexion
and rotation.
Underlying bony disorders of the hip, such as hip
dysplasia, femoral retroversion, coxa valga, and
slipped capital femoral epiphysis, can place the labral
tissue at a greater risk of tear.
Acetabular labral tears
commonly found in the anterior superior aspect of the
acetabulum.
These tears usually present with sharp anterior hip and
groin activity related pain.
Pain is described as sharp or pinching and is usually with
locking.
anterior impingement and FABER test may be positive.
Magnetic resonance arthrography is the most reliable
study .
T2-weighted axial magnetic
resonance arthrogram
demonstrating a tear of the
anterosuperior labrum (arrow).
Nonsurgical treatment for labral tears :
intra-articular injections (diagnostic and
therapeutic).
rest, activity modification,Oral anti-inflammatory
medication,and physical therapy.
Hip arthroscopy
It is : the preferred surgical approach for the
management of isolated labral tears.
safe and effective ، good results
Study
30 patients underwent arthroscopic debridement.
At 17-month follow-up:
significant improvements were found in the Harris hip
score (preoperative, 57.6; postoperative, 89.2).
Three of the patients in this group experienced a recurrent
labral tear.
Femoroacetabular Impingement
(FAI) is a process by which a nonspherical femoral
head exists within a hemispheric acetabulum,
leading to
labral and chondral pathology and hip arthritis.
Patients present with anterior groin pain, which is
worsened by flexion and rotation of the hip.
Round lucencies seen in the femoral neck due to a
herniation of synovium through a cortical defect.
Surgical management of FAI is:
aimed at correcting the
abnormal osseous anatomy.
Both arthroscopic and open
techniques have been
successful.
A peripheral compartment
arthroscopic view of an
adolescent hip following
femoral osteoplasty for
the management of
impingement.
The proximal femoral
physis is visualized.
Coxa saltans is classified as intra
articular,internal, or external.
The intra-articular variant is the result of :
labral tears,loose bodies, or cartilage flaps with
in the hip joint.
Coxa saltans external is usually associated with
snapping of the iliopsoas tendon band or the
anterior border of the gluteus maximus muscle
over the greater trochanter.
Patients with symptomatic internal snapping hip
syndrome often present with anterior groin pain
and snapping.
A dynamic external rotation test may reproduce
snapping or pain.
Recurrent snapping of the psoas tendon may
cause impingement on the labrum and lead to
labral tears.
Treatment
nonsurgical treatment of symptomatic
coxa saltans externa consists of stretching,
physical therapy, (NSAIDs), and corticosteroid
injections.
Surgical intervention:
open surgery or arthroscopic to lengthen the
iliopsoas tendon band and manage associated
trochanteric bursitis
Apophyseal Avulsions
commonly encountered around the adolescent
hip because of the inherent weakness of the
remaining open physis combined with repetitive
stress to the epiphyseal plate.
These injuries result from indirect trauma caused
by a sudden forceful muscular contraction
Avulsion injuries are commonly seen in athletes whose
sports require rapid acceleration and deceleration.
Study: In 203 avulsion fractures ischial tuberosity
54% anterior inferior iliac spine fractures 22%, and
anterior superior iliac spine fractures 19%.
Patients present with acute pain and swelling that
follows a sudden, noncontact traumatic incident.
tenderness to palpation and pain with passive stretch
of the muscle attached to the avulsed fragment.
Radiographic evaluation is to confirm the diagnosis and
allows to assess the size of the avulsed fragment and
the amount of fracture displacement.
The initial management rest, ice,NSAIDs, and protected
weight bearing with crutches until symptoms resolve;
physical therapy.
surgical indications :are for ischial tuberosity fractures
with >2 cm displacement and for symptomatic
nonunion, chronic pain, and impaired function.
Arthroscopic images of iliopsoas tendon lengthening.
A, The iliopsoas tendon (arrow) identified via a transcapsular approach in
the central compartment.
B, The tendinous portion is lengthened under direct visualization (arrow).
AP radiograph of a 13-yearold boy with right anterior
superior iliac spine avulsion
fracture (arrow).
AP radiograph of a 14 years-old
girl demonstrating a right
lesser trochanteric avulsion
fracture (arrow).
AP radiograph (A) and AP (B) and lateral (C) three-dimensional CT
images demonstrating evidence of subspine impingement from a
previous anterior inferior iliac spine avulsion fracture (arrow), which
later required arthroscopic decompression and labral repair
Hip Instability
classified as traumatic or atraumatic
Traumatic hip dislocation generallyresults from an
axially applied force against a flexed knee with the
hip in the neutral or adducted position.
Generally follows a high-energy trauma,
and associated injuries are common.
clinicaly severe pain and the hip held in the flexed,
adducted, and internally rotated position.
Hip Instability
Plain radiographs confirm the diagnosis, and
emergent reduction is indicated.
Following reduction,plain radiographs and CT
or MRI are indicated to confirm a congruent
reduction and to evaluate for intra-articular
pathology.
Management of hip instability
restricted weight bearing for 6 weeks
postreduction management.
consider capsular or other soft-tissue laxity as a
cause of persistent hip instability.
Initially,this is managed with physical therapy.
Management of hip instability
Arthroscopic thermal capsulorrhaphy hasalso been
proposed.
In patients with a nonconcentric reduction or
notable acetabular fracture of the posterior wall,
surgical intervention should be undertaken.
Arthroscopy has been used to remove
loose bodies.
Summary
It is the role of the pediatric orthopaedic surgeon and sports
medicine provider to properly diagnose and manage Hip
pathology in the adolescent athlete.
Appropriate workup and management can be often used
effectively in adolescent athlete.
Nonsurgical management includes activity modification, physical
therapy and anti-inflammatory medication
Surgical management of both intra- and extra-articular hip
pathology can safely be used when clinically indicated.