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9/26/2014 Overview Extra-Articular Considerations • Intra-Articular – Labral-chondral Lesions • • • • RobRoy L. Martin PhD, PT, CSCS Duquesne University Pittsburgh, PA UPMC Center for Sports Medicine FAI Hypermobility Hypomobility Traumatic • Extra-Articular – Musculoskeletal – Non-Musculoskeltal 1 2 Intra- vs Extra-Articular Pathology • Diagnosing Intra-articular pathology: • Extra-Articular – Insidious onset of sharp or aching groin pain that limits activity. – Physical examination: – Musculoskeletal – Non-Musculoskeletal • Limited hip flexion, internal rotation, and abduction range of motion • Positive Flexion-Adduction-Internal Rotation Impingement test • Positive FABER test • Recommendation in FAI: – B grade- Evidence levels 2 and 3 » » » » Clohisy JC (2009) Clin Orthop Relat Res Johnston TL (2008) Arthroscopy Philippon MJ (2007) Traumatol Arthrosc Tannast M (2007) J Orthop Res 3 4 Nerve Involvement: Peripheral Entrapment Nerve Involvement • Entrapments in the posterior hip region: – Sciatic – Pudendal • Entrapments in the anterior hip region: – – – – – 5 Obturator Femoral Lateral femoral cutaneous Ilioinguinal-iliohypogastric Genitofemoral 6 1 9/26/2014 Posterior Nerve Entrapments The Seated Palpation Test • Pain: – Pudendal Nerve: • Medial to ischum – Ischiofemoral Entrapment involving the sciatic nerve: • Lateral to the ischium – Deep Gluteal Nerve Entrapment at the level of the external rotators and piriformis muscle: • sciatic nerve entrapment by these muscles. • The Seated Palpation Test 7 8 Greater Trochanter-Ischial Impingement: A Potential Source of Posterior Hip Pain Sciatic Nerve Entrapment • Sciatic nerve – Courses distally through the subgluteal space anterior to the piriformis and posterior to the obturator, gemelli and quadratus femoris muscles RobRoy L. Martin, Ph.D., PT, CSCS Professor Department of Physical Therapy John G. Rangos Sr., School of Health Sciences Duquesne University Pittsburgh, PA • Piriformis/Deep Gluteal Syndrome Benjamin R. Kivlan PT, OCS, SCS, CSCS Department of Physical Therapy John G. Rangos Sr., School of Health Sciences Duquesne University Pittsburgh, PA – The nerve exits the posterior hip lateral to the ischial tuberosity and deep to the long head of the biceps • Ischial Tunnel Syndrome 9 METHODS: Greater-Trochanteric Impingement Testing Hal D. Martin D.O. Medical and Research Director Hip Preservation Center Baylor University Medical Center Dallas, TX 10 CONCLUSION • The greater trochanter can impinge on the ischium when the hip is extended from 90° flexion in a 60° externally rotated position. THIRD TEST POSITION: Patrick-FABER test • Positive finding was contact between the greater trochanter and ischium • This impingement occurred more commonly when the hip was in 30° abduction compared to neutral abduction. • The Patrick-FABER test reproduced greater trochanterticischial impingement in almost all specimens. SN Isch Greater Trochanter=GT Isch=Ischial Tuberosity Sciatic Nerve=SN GT 11 12 2 9/26/2014 Clinical Significance Sciatic Nerve Entrapment Figure: Posterior view of Patrick–FABER Test • Symptoms: • A source of hip pain that has not been described is greater trochantertic-ischial impingement. • Sciatic nerve impingement between the greater trochanter and ischium can occur when the hip is in a flexed, abducted and externally rotated position. – Buttock pain 81%(N=27), – Inability to sit greater than 30 minutes 76%(N=25), – Parasethsia 57%(N=19), – Pain distal to the knee 30%(N=10) • GT SN Sciatic nerve compression by: – Fibrovascular scar bands • Piriformis • Obturator Internus • Quadratus Femoris Isch • The Patrick-FABER test may be a useful clinical test to assess for greater trochantertic-ischial impingement Greater Trochanter=GT; Isch=Ischial Tuberosity; Sciatic Nerve=SN » Martin HD, Shears SA, Johnson JC, Smathers AM, Palmer IJ (2011) The endoscopic treatment of sciatic nerve entrapment/deep gluteal syndrome. Arthroscopy 27: 172-181. 13 Sciatic Nerve Entrapment: Level of External Rotators 14 The Active Piriformis Test • Symptoms – With the patient in the lateral position, the examiner palpates the piriformis. – The patient drives the heel into the examining table thus initiating external hip rotation while actively abducting and externally rotating against resistance. – Buttock pain – Inability to sit for more than 30 minutes • Examination – Seated Palpation Test – Active Piriformis test – Seated Piriformis stretch 15 Seated Piriformis Stretch Test 16 Sciatic Nerve Entrapment • Diagnosis – Positive Active Piriformis Test and/or Seated Piriformis Stretch – The patient is in the seated position with knee extension. – The examiner passively moves the flexed hip into adduction with internal rotation while palpating 1cm lateral to the ischium (middle finger) and proximally at the sciatic notch (index finger). • Sensitivity = 0.91 • Specificity = 0.80 • Diagnostic Odds Ratio = 42 Martin HD, Kivlan, BR, Martin RL. Diagnostic accuracy of clinical tests for sciatic nerve entrapment. Knee Surgery, Sports Traumatology, Arthroscopy. 22:882-888; 2014. 17 18 3 9/26/2014 Sciatic Nerve Entrapment: Ischiofemoral Pudendal Nerve • Ischial Tunnel Syndrome. – Entrapment of the sciatic nerve near the ischium or proximal hamstring – The insertion of the hamstring tendon can be thickened due to trauma or partial hamstring avulsion – Symptoms radiating down the posterior thigh to the popliteal fossa aggravated by running • The pudendal nerve exits the pelvis through the greater sciatic foramen between the piriformis and superior gemellus muscles. • It crosses the sacrospinous ligament near the ischial spine. • The nerve then enters Alcock’s canal, which is formed by the obturator fascia and sacrotuberous ligament. • In the posterior aspect of the Alcock`s canal, the pudendal nerve gives rise to the inferior rectal nerve, perineal nerve, and dorsal nerves of the penis or clitoris. 19 Pudendal Nerve 20 Anterior Nerve Entrapments • Symptoms usually consist of pain in the penis, scrotum, labia, perineum, or anorectal region. – Obturator – Femoral – Lateral femoral cutaneous – Ilioinguinal-iliohypogastric – Genitofemoral • Pain is generally worsened by sitting, except when sitting on a toilet seat. • The physical examination should relatively normal including normal sensation. • Careful palpation should be done looking specifically for tenderness medial to the ischium as well as at the sciatic notch, piriformis, midischial region, and obturator internus. 21 Obturator Nerve 22 Femoral Nerve • Entrapment due to thick fascia overlying the short adductor muscle • Symptoms of paresthesia, numbness, and/or pain located the medial thigh • Movements of abduction and extension increase the symptoms by stretching the obturator nerve. 23 • Entrapment occurs: – Iliacus compartment – Inguinal ligament 24 4 9/26/2014 Femoral Nerve Lateral Femoral Cutaneous Nerve • The main clinical feature of patients with femoral nerve entrapment is quadriceps muscle weakness. • Pain, numbness, and paresthesia may also be noted in the anterior thigh and with saphenous nerve involvement noted in the anteromedial knee joint, medial leg, and foot. • Symptoms are typically worsened with movements of hip extension and knee flexion, such as with the Modified Thomas test position. • Patients with proximal nerve injury can present with iliopsoas muscle weakness. – • However, the psoas muscle is also directly innervated by the L2 and L3 nerve roots and may function adequately without femoral nerve innervation. Severe femoral nerve lesions produce quadriceps muscle atrophy and an absence of the patellar tendon reflex. • Entrapment can occur as it perforates the inguinal ligament • Obesity and pregnancy are risk factors • Symptoms of tingling, stinging, or burning sensation in the anterior lateral thigh with associated to numbness or hypersensitivity to touch. 25 Ilioinguinal-iliohypogastric • – • • Arch and Twist Maneuver Entrapment of the ilioinguinal and iliohypogastric need to be considered in those with pain in the abdominal wall, groin, thigh, and genital region. – • 26 Particularly after trauma to the abdomen region. Abdominal surgeries, including hernia repairs, can cause entrapment of these nerves and in particular the ilioinguinal nerve. Stabbing pain in the distribution of the nerve that is aggravated by stretching movement is the most common complaint. Tinel’s sign may be able to be elicited in the area of abdominal entrapment. Madura et al. suggests an “arch and twist” maneuver to stretch the affected nerves and recreate symptoms. Madura JA, Madura JA, 2nd, Copper CM, Worth RM. Inguinal neurectomy for inguinal nerve entrapment: an experience with 100 patients. American journal of surgery. 2005;189:283-287 27 Genitofemoral 28 Athletic Pubalgia/Sports Hernia • Entrapment of this nerve can occur after abdominal surgery or in rare cases blunt trauma to the groin. • Entrapment of the genital branch can cause symptoms in the genital region while entrapment of the femoral branch can cause symptoms in a small area in the proximal anterior thigh. • Spectrum of chronic pubic/inguinal pain • Tear in the muscles/tendons of the lower abdomen. • Typically movements into hip extension can aggravate symptoms. 29 30 5 9/26/2014 Pathogenis of Athletic pubalgia ATHLETIC PUBALGIA • Hip flexor muscles tilt the pelvis forward and stretch the lower abdominal wall muscles • Repetitive forces to pubic symphysis or tendinous insertions of the adductors and rectus abdominus • Disruption of inguinal canal components (external oblique aponerosis, conjoined tendon, etc.) • Often noted in sports that require forceful, repetitive twisting and turning 31 32 Athletic Pubalgia Athletic pubalgia • Symptoms: • Hip ROM – chronic pain, often during exertion. – Sharp burning pain – Localized to the lower abdomen and inguinal region – Full and painless – except minor soreness at endrange hip abduction • Manual Muscle Testing – Weak and painful adduction on involved side – Weak and painful iliopsoas on involved side – Inguinal region pain with resisted sit-up • radiates to the adductor region and potentially testicular region • Palpation – Tenderness superior to inguinal ligament region 33 Femoral Neck Stress Fractures Femoral Neck Stress Fractures • Etiology – At the femoral neck, fractures may occur at the superior aspect due to tensile forces or on the inferior aspect secondary to the compressive forces. – Femoral neck stress fractures are the result of excessive stress without sufficient time for remodeling. In effect, the catabolic process (break down) of bone exceeds the anabolic process (build up). – In the majority of cases, improper training is the most obvious cause of a stress fracture. • Risk factors: – – – – – 34 • Epidemiology – Incidence • ~15% of runners will develop a stress fracture. Of these 15%, ~10% are classified as femoral neck stress fractures. – Gender high body mass index (BMI) decreased fitness improper footwear change of running surface prior history of a stress fracture. • Females especially those with the female athlete triad (disordered eating, menstrual cycle dysfunction and osteoporosis) seem to be at greater risk. 35 36 6 9/26/2014 Femoral Neck Stress Fracture • Groin pain to anteromedial thigh • Pain with weight bearing activity Non-Musculoskeletal Source of hip pain – With progression night pain can occur • Physical examination – Often negative – Pain at the extreme of internal and external rotation • Advanced imaging techniques are often necessary. 37 38 Differential Diagnosis Symptom Presentation • Bilateral hip pain • Poorly localized • Identify “RED FLAGS” – Systems Review • • • • • – Unable to point to a specific spot CV/pulmonary Integumentary Neuromuscular Musculoskeletal Communication • No specific movements aggravate symptoms • All movements increase symptoms with empty end-feels • Aggravated by activities that increase intraabdominal pressure – (i.e.-OX3, emotional-behavior response) – i.e. Coughing, bowel movements 39 40 Key Questions Pain Locations – Changes in bowel or bladder function • Unusual stool or urine color – Changes in menstruation • Do symptoms correlate with menstrual cycle? – – – – – – – Painful menstruation Possibility of being pregnant Painful intercourse Sexual difficulty Discharge from penis or vagina Fever chills nausea, vomiting Recent infections or illness • “Just cannot get rid of a cold” • “The cold keeps coming back” – – – – 41 Unusual changes in skin including rashes Unusual fatigue, irritability or difficulty sleeping Loss appetite Unexplained weight loss 42 7 9/26/2014 Non-Musculoskeletal Source of hip pain Non-Musculoskeletal Source of hip pain • Cancer- Bone Tumors • Vascular- Arterial Insufficiency – Hodgkin's lymphoma – AVN • Enlarged and tender lymph glands • Long term use of corticosteroids, immunosuppressants – Best predictor for CA is previous history of CA – Abdominal aortic aneurysm • Rapid onset of sharp sever groin pain • Pulsating abdominal pain • Can be associated with back pain 43 Non-Musculoskeletal Source of hip pain 44 Non-Musculoskeletal Source of hip pain • Urogenital • Psoas Abscess – Abdominal pain and tenderness in femoral triangle – Psoas spasm – Fever and sweats – Changes in bladder function – Genital symptoms • Testicular Cancer • Crohns’ Disease – Testicular irregularities – A type of inflammatory bowel disease – Skin rash associated with the onset of hip pain • Endometriosis • Pelvic inflammatory conditions • Prostrate impairment • Reiter’s Syndrome – Also called reactive arthritis – Occurs as a reaction to certain infections of the reproductive system and digestive system. • Kidney • Tuberculosis – Fevers chills 45 46 Non-Musculoskeletal Source of hip pain Conclusion • Pagets’ Disease • Intra-Articular • Caused by the excessive breakdown and formation of bone, followed by disorganized bone remodeling. • This causes affected bone to weaken, resulting in pain, misshapen bones, fractures and arthritis in the joints near the affected bones – Labral-chondral Lesions • • • • • Other metabolic Diseases FAI Hypermobility Hypomobility Traumatic • Extra-Articular – Gaucher’s disease – Ochronosis – Hemochromatosis – Musculoskeletal – Non-Musculoskeltal 47 48 8 9/26/2014 Thank You 49 9