Evaluation and Management of Hip and Pelvis Injuries

Hip Pain in an Athlete

ABSTRACT

Hip pain is a common complaint in sports, and narrowing the differential diagnosis can be difficult. Many etiologies are secondary to overuse and respond well to nonsurgical treatment. The increased use of point-of-care ultrasound has helped provide timely and accurate diagnoses and some guided treatments. The hip is in close proximity to the abdomen and pelvis, and clinicians should be familiar with nonmusculoskeletal pain generators. This article is a comprehensive review of hip pain etiologies in athletes.

Care for the patient with hip pain

ABSTRACT

Hip pain is a common and sometimes disabling condition that affects adults in the primary care setting. The NP must understand the assessment, diagnosis, and treatment options for patients with hip pain. Proper care of these patients often involves conservative medical management and coordination with physical therapy.

Sex-related differences in hip and groin injuries in adult runners: a systematic review

OBJECTIVES

Hip/groin running-related injuries (RRIs) are relatively uncommon. It is unclear if runners of either sex are disproportionately affected. Our objective was to systematically review differences in hip/groin RRIs between males and females.

DATA SOURCES

A structured and comprehensive search of four medical literature databases was performed (PubMed, Embase, Ovid Medline, and CINAHL). Terms searched were as follows: risk, epidemiology, hip injury, groin injury, overuse injury, running, sprinting, and track and field.

STUDY SELECTION

Studies reporting sex-specific data on hip/groin RRIs in adult runners were included. Data was extracted and reviewed independently by two authors.

STUDY APPRAISAL AND DATA SYNTHESIS

Sex-specific injury rates, risk factors, and return to sport (RTS) following hip/groin RRI were extracted. Risk of bias was assessed using the Joanna-Briggs Institute Critical Appraisal Tool.

RESULTS

Ten studies with 7,353 total runners were included: 2,315 (47%) males and 2,559 (53%) females. The mean age of the included runners was 37.3 ± 8.9 years and the mean weekly running distance was 10.4 ± 8.4 km. Hip/groin injuries comprised 10.1% (491/4,874) of total RRIs, including 6.3% of RRIs sustained by males and 11.0% by females. Three studies reported significantly higher rates of hip/groin RRIs in female runners. One study reported significantly higher rates of gluteus medius and adductor RRIs for females and males, respectively. One study identified female sex as an independent risk factor for hip/groin RRIs. Three studies reported on RTS after hip/groin RRIs: the pooled RTS rate was 81.4% (57/70) at 1 to 368 days after injury.

LIMITATIONS

Data was pooled when possible; however, there was considerable clinical, methodological, and statistical heterogeneity across studies.

CONCLUSIONS

Hip/groin RRIs comprise a greater percentage of total injuries among injured female runners relative to males. Females may be at a higher risk for sustaining hip/groin RRIs though more research on risk factors and RTS is needed.

Caring for adults with hip pain

This article discusses the pathophysiology, assessment techniques, and management of hip pain in adults and the role of nurses in caring for patients with hip pain.

2019 Marathon of Rome. Hamstring injuries in long distance runners: influence of age, gender, weight, height, numbers of marathon and impact profile

BACKGROUND

Hamstring diseases are one of the most widespread diseases in athletes, especially in runners, sprinters, and endurance athletes. Notwithstanding the importance of the problem, risk factors are still marginally known. This transversal study analyzes the correlation between Hamstring tendinopathy and hamstring strains and age, gender, weight, height, number of marathons, and impact profile in athletes who took part in the 2019 Rome Marathon.

METHODS

At the 2019 Marathon of Rome, 700 runners (484 males and 216 females; mean age: 43.6 years, range 17-80 years) filled the VISA-H and FASH questionnaires. An adequately skilled orthopedic surgeon made a diagnosis of Hamstring tendinopathy and Hamstring strain injuries in line with clinical criteria.

RESULTS

A diagnosis of Hamstring tendinopathy was made in 537 participants while in 624 of hamstring strains. There was evidence of a positive correlation statistically significant between age, weight and impact profile with Hamstring strain injuries, while there was no association between sex and number of marathons and the Hamstring strains. No statistically significant positive correlation was found between all of the parameters analyzed and VISA-H. The association between VISA-H score and FASH score has resulted statistically significant.

CONCLUSIONS

In marathon athletes, there was not found evidence of a statistically significant correlation between gender, weight, height, number of marathons, impact profile and Hamstring tendinopathy. Nonetheless, age, weight and impact profile were associated with Hamstring strains, while sex and number of marathons had not shown statistically significant positive association with Hamstring strain injuries.

Surgical and Non-surgical Treatment Options for Piriformis Syndrome: A Literature Review

Context

Piriformis syndrome is a solely clinical diagnosis that often eludes the practitioner and goes underdiagnosed. PS is a pain syndrome and for those it affects, causes persistent pain and limits daily activity and work capacity. It is a form of deep gluteal syndrome that needs to be considered on the differential of low back pain as it comprises between 0.3% - 6% of all low back pain cases and is frequently underdiagnosed. Piriformis syndrome may be primary due anatomic anomalies or secondary, though the majority of cases are secondary to some insult. The objective of this manuscript is to provide a description of the epidemiology and presentation of piriformis as well as both non-operative and operative treatment options. We review all of the recent clinical evidence regarding the aforementioned therapies.

Evidence Acquisition

Literature searches were performed using the below MeSH Terms using Mendeley version 1.19.4. Search fields were varied until further searches revealed no new articles. All articles were screened by title and abstract. Decision was made to include an article based on its relevance and the list of final articles was approved three of the authors. This included reading the entirety of the article. Any question regarding the inclusion of an article was discussed by all authors until an agreement was reached.

Results

Medical management and physical therapy show some promise; however, when conservative treatment fails minimally invasive methods such as steroid injections, botulinum toxin injections, dry needling are all efficacious and there is substantial clinical evidence regarding these therapies. In those patients in which minimally invasive techniques do not result in an adequate relief of pain and return of function, endoscopic release can be considered. Endoscopic release is far superior to open release of the piriformis syndrome given the higher success and lower rate of complications.

Conclusions

Piriformis syndrome is an important differential diagnosis in the work up of lower back pain and should not be ruled out with proper examination and testing. Clinicians should consider medical management and conservative management in the initial treatment plan for piriformis syndrome. There are many options within the conservative management and the literature shows much promise regarding these. Physical therapy, steroid injections, botulinum toxin injections, and dry needling are all potentially effective therapies with few adverse effects. Surgical options remain as gold standard, but only when conservative management has failed and the symptoms are significant to affect daily living activities. Endoscopic decompression of the sciatic nerve with or without release of the piriformis muscle has a reported high likelihood of success and a low complication rate. Current literature supports the preference of the endoscopic approach over the open approach due to improved outcomes and decreased complications. Further research is to well define the metrics for the diagnosis of piriformis syndrome and may include a need to develop diagnostic criteria.

HIP AND PELVIC STABILITY AND GAIT RETRAINING IN THE MANAGEMENT OF ATHLETIC PUBALGIA AND HIP LABRAL PATHOLOGY IN A FEMALE RUNNER: A CASE REPORT

BACKGROUND

Athletic pubalgia is a prevalent injury in athletes who kick, pivot, and cut, however it is poorly described in the literature. Many athletes with this diagnosis fail conservative management secondary to continued pain with activity and require surgical intervention for return to sport.

PURPOSE

The purpose of this case report is to describe an intervention strategy focusing on gait retraining and hip and lumbopelvic stability for a female runner diagnosed with athletic pubalgia and a labral tear of the hip.

CASE DESCRIPTION

This case report involved a 45-year-old female runner who was seen for 14 visits, from examination to return to sport, with a follow up at 12 months post discharge. Interventions included hip, pelvic, and lumbar stability exercises, and gait retraining. Outcomes measurements included: pain on the numeric pain rating scale, the Lower Extremity Functional Scale (LEFS), gait mechanics, strength, and participation in sport.

OUTCOMES

At discharge the subject demonstrated improved strength of all muscle groups and changes in lower extremity running biomechanics. Changes in running mechanics included increased cadence, decreased pelvic drop, diminished over striding, and improved knee control with less valgus movement during the stance phase of gait. The subject reported no pain with running or recreational activities at discharge and follow up at 12 months post discharge.

DISCUSSION/CONCLUSION

Most of the literature on conservative rehabilitation for athletic pubalgia focuses on athletes whose sports require pivoting and kicking. The literature provides little information on gait analysis and retraining for runners with a diagnosis of athletic pubalgia and/or hip labrum tears. The program used in this case report including gait retraining and hip, pelvic, and lumbar stability training allowed for full return to running in a 45-year-old female with a diagnosis of hip labrum tear and athletic pubalgia. Further research is needed to discern best conservative treatment for runners with athletic pubalgia and/or hip labral tears.

LEVEL OF EVIDENCE

4.

Conservative management of tendinopathies around hip

BACKGROUND

The anatomy of hip is widely complex and several anatomical structures interact and contribute to its functioning. For position and role, hip and the surrounding tendons, which have their insertion around, are overstressed and often overloaded, especially in athletes. This could lead to the developing of several tendinopathies, among which the differential diagnosis is often complicated. Many conservative treatments are used in clinical practice, while actually, no defined conservative protocol is recommended.

METHODS

This is a review article. The aim of this manuscript is to evaluate the current evidences about the effectiveness of conservative management in hip tendinopathies.

CONCLUSION

Conservative treatment is effective in the management of hip tendinopathies and may be considered the first-line approach for patients affected. However, there is lack of evidences about which is the most effective treatment. Exercise therapy seems to provide long-term pain relief, but the literature is still lacking about the correct type, dose, posology, intensity of exercise prescribed. Further studies about different local approaches, as PRP or hyaluronic acid injections, may be encouraged.

LEVEL OF EVIDENCE

I.