An Overview of Hip Injuries in Running

Iliotibial Band Origin Tendinopathy Is an Underrecognized Cause of Anterolateral Hip Pain: A Narrative Review and Clinical Commentary

ABSTRACT

Hip pain is a common concern among athletes. With gluteal tendinopathy, femoroacetabular impingement, and osteoarthritis predominating sports medicine and musculoskeletal practices, less common etiologies may be overlooked. Complex pelvic anatomy and variable pain referral patterns may make identifying an accurate diagnosis challenging. Employing a systematic approach to evaluation and having a thorough understanding of hip region anatomy are essential. A potentially overlooked cause of anterolateral hip pain is iliotibial band origin tendinopathy. Patients often present with pain around the anterolateral hip and tenderness to palpation at the anterolateral iliac crest. While patients with iliotibial band origin tendinopathy usually respond to nonsurgical intervention, there is little literature to guide evaluation and treatment, highlighting a gap in the recognition of this condition. The purpose of this narrative review is to describe the anatomy of the proximal iliotibial band origin, outline the clinical diagnosis and imaging findings of ITBOT, and summarize current treatment options.

Hip Range of Motion During Passive and 1-Leg Exercises Is Greater in Women: A Meta-analysis and Systematic Review

PURPOSE

To summarize sex-related differences in hip range of motion (ROM), including flexion, extension, abduction, adduction, internal rotation, and external rotation.

METHODS

We performed a systematic search of 3 databases (PubMed, CINAHL [Cumulative Index to Nursing and Allied Health Literature], and Embase). The search terms were as follows: hip, pelvis, range of motion, kinematic, men, and women. Included studies reported sex-specific data on hip ROM in healthy, uninjured adults. To generate hip ROM mean differences, a DerSimonian-Laird random-effects model was used. Effect sizes were pooled for each exercise. Subgroup analyses compared hip ROM by physical activity group: passive ROM, 1-leg hop or jump, 2-leg hop or jump, 2-leg drop or landing, 1-leg squat, 2-leg squat, walking, and jogging/running. Positive effect sizes represent greater ROM in women.

RESULTS

Thirty-eight studies with 3,234 total subjects were included; of these subjects, 1,639 were women (50.1%). The mean age was 25.3 years. An effect difference was considered statistically significant if P < .05 and clinically significant if the mean difference was greater than 4.0°. Women showed statistically and clinically significantly greater hip flexion in passive ROM (mean difference, 6.4°) and during the 1-leg hop or jump exercise (mean difference, 6.5°). Women also showed statistically and clinically significantly greater hip adduction during the 1-leg hop or jump (mean difference, 4.5°) and 1-leg squat (mean difference, 4.4°) exercises, as well as statistically and clinically significantly greater hip internal rotation in passive ROM (mean difference, 8.2°). In contrast, men showed statistically and clinically significantly greater flexion during the 2-leg hop or jump exercise (mean difference, -9.1°). No clinically significant differences in extension, abduction, or external rotation were found between women and men.

CONCLUSIONS

On average, women showed statistically and clinically significantly greater flexion, adduction, and internal rotation during passive and 1-leg exercises whereas men showed statistically and clinically significantly greater flexion during the 2-leg hop or jump exercise.

LEVEL OF EVIDENCE

Level IV, meta-analysis and systematic review of Level II-IV studies.

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.

Ultrasound-guided bursal injections

The native bursa is a structure lined by synovium located adjacent to a joint which may serve to decrease friction between the tendons and overlying bone or skin. This extra-articular structure can become inflamed resulting in bursitis. Steroid injections have proven to be an effective method of treating bursal pathology in various anatomic locations. Performing these procedures requires a thorough understanding of relevant anatomy, proper technique, and expected outcomes. Ultrasound is a useful tool for pre procedure diagnostic evaluation and optimizing needle position during these procedures while avoiding adjacent structures. The purpose of this article is to review core principles of ultrasound-guided musculoskeletal procedures involving bursae throughout the upper and lower extremities.

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.

Imaging of common hip pathologies in runners

Running is an increasingly popular sport and form of exercise. Because of the importance of the hip in the biomechanics involved with running, forming the primary connection between the axial and appendicular skeleton of the lower extremities, accurate diagnosis and reporting of hip pathology are vital for appropriate management. This review provides an overview of the most common hip pathologies and injuries encountered in runners. Radiologic studies, primarily conventional radiography and magnetic resonance imaging (MRI) provide useful diagnostic information and should be used in combination with clinical findings to help guide therapeutic management.

A Pilot Study of Plantar Mechanics Distributions and Fatigue Profiles after Running on a Treadmill: Using a Support Vector Machine Algorithm

The treadmill is widely used in running fatigue experiments, and the variation of plantar mechanical parameters caused by fatigue and gender, as well as the prediction of fatigue curves by a machine learning algorithm, play an important role in providing different training programs. This experiment aimed to compare changes in peak pressure (PP), peak force (PF), plantar impulse (PI), and gender differences of novice runners after they were fatigued by running. A support vector machine (SVM) was used to predict the fatigue curve according to the changes in PP, PF, and PI before and after fatigue. 15 healthy males and 15 healthy females completed two runs at a speed of 3.3 m/s ± 5% on a footscan pressure plate before and after fatigue. After fatigue, PP, PF, and PI decreased at hallux (T1) and second-fifth toes (T2-5), while heel medial (HM) and heel lateral (HL) increased. In addition, PP and PI also increased at the first metatarsal (M1). PP, PF, and PI at T1 and T2-5 were significantly higher in females than in males, and metatarsal 3-5 (M3-5) were significantly lower in females than in males. The SVM classification algorithm results showed the accuracy was above average level using the T1 PP/HL PF (train accuracy: 65%; test accuracy: 75%), T1 PF/HL PF (train accuracy: 67.5%; test accuracy: 65%), and HL PF/T1 PI (train accuracy: 67.5%; test accuracy: 70%). These values could provide information about running and gender-related injuries, such as metatarsal stress fractures and hallux valgus. Application of the SVM to the identification of plantar mechanical features before and after fatigue. The features of the plantar zones after fatigue can be identified and the learned algorithm of plantar zone combinations with above-average accuracy (T1 PP/HL PF, T1 PF/HL PF, and HL PF/T1 PI) can be used to predict running fatigue and supervise training. It provided an important idea for the detection of fatigue after running.

Intertrochanteric hip stress fracture in a male ultramarathon runner

Stress fractures are injuries frequently seen in high-performance athletes, especially runners. In the femur, the most commonly affected locations are the femoral neck, condylar area and proximal shaft. Intertrochanteric fractures are much more common in the elderly population, especially among those with osteoporosis, but they can also be a result of high-energy repetitive mechanisms. We present a case of an intertrochanteric stress fracture in a young male runner. The diagnosis was suspected after persistent pain following his first marathon, and it was confirmed with an MRI. Operative fixation of the fracture was performed 22 days after the pain started, which allowed the patient to return to his activities, including 50 km marathon 4 months following the surgery.

Differences in Muscle Demand and Joint Contact Forces Between Running and Skipping

Skipping has been proposed as a viable cross-training exercise to running due to its lower knee contact forces and higher whole-body energy expenditure. However, how individual muscle forces, energy expenditure, and joint loading are affected by differences in running and skipping mechanics remains unclear. The purpose of this study was to compare individual muscle forces, energy expenditure, and lower extremity joint contact forces between running and skipping using musculoskeletal modeling and simulations of young adults (n = 5) performing running and skipping at 2.5 m·s−1 on an instrumented treadmill. In agreement with previous work, running had greater knee and patella contact forces than skipping which was accompanied by greater knee extensor energetic demand. Conversely, skipping had greater ankle contact forces and required greater energetic demand from the uniarticular ankle plantarflexors. There were no differences in hip contact forces between gaits. These findings further support skipping as a viable alternative to running if the primary goal is to reduce joint loading at the commonly injured patellofemoral joint. However, for those with ankle injuries, skipping may not be a viable alternative due to the increased ankle loads. These findings may help clinicians prescribe activities most appropriate for a patient’s individual training or rehabilitation goals.

Hip Pain: Imaging of Intra-articular and Extra-articular Causes

Hip pain is a common and complex clinical entity. The causes of hip injuries in athletes are many and diverse, requiring efficient, accurate diagnosis for proper management. Imaging is an important step in the clinical evaluation of hip pain, and familiarity with multiple imaging modalities as well as characteristic imaging findings is a helpful tool for sports medicine clinicians. This article discusses imaging recommendations and gives imaging examples of common causes of intra-articular and extra-articular hip pain including femoroacetabular impingement, labral tears, cartilage defects, ligamentum teres injuries, snapping hip syndrome, femoral stress injuries, thigh splints, athletic pubalgia, avulsion injuries, and hip dislocation.

Non-surgical treatment as the first step to manage peritrochanteric space disorders

PURPOSE

Greater trochanter pain syndrome (GTPS) or lateral hip pain terms include external snapping hip, trochanteric bursitis and gluteus medius or minimus pathology. The aim of this review is to update the most recent knowledge about non-surgical management of peritrochanteric disorders.

METHODS

A literature review was performed including articles most relevant in the last years that were focused in non-surgical treatment of peritrochanteric disorders.

RESULTS

Conservative treatment still has a place and includes activity modification, NSAIDs, analgesics, physiotherapy, home training, local corticosteroid injection (CSI) and shock wave therapy (SWT). These non-surgical alternatives have demonstrated good clinical results with low rate of complications.

CONCLUSION

Most patients tend to resolve GTPS or lateral hip pain with non-surgical management in the mid-term but when everything failed, surgical options should be evaluated. The next frontier that will be a game changer is to determine an individualized treatment plan based on the exact pathology.

LEVEL OF EVIDENCE

V.

Hip Injuries in the Adolescent Athlete

This article provides concise and up-to-date information on the most common hip pathologies that affect adolescent athletes. We cover the evaluation and treatment of avulsion injuries, stress fractures, slipped capital femoral epiphysis (SCFE), femoroacetabular impingement, developmental dysplasia of the hip, Legg-Calve-Perthes disease, and coxa saltans focusing on minimizing advanced imaging and using conservative therapy when applicable. Although this is not an all-encompassing list of disorders, it is key to understand these hip pathologies because these injuries occur commonly and can also have detrimental complications if not diagnosed and addressed early, especially SCFE and femoral neck stress fractures.

Effects of Inflammatory Disease on Clinical Progression and Treatment of Ischiogluteal Bursitis: A Retrospective Observational Study

Introduction:

The symptoms of Ischiogluteal Bursitis (IGB) are often nonspecific and atypical, and its diagnosis is more challenging. Moreover, it is difficult to predict cases of chronic progression or poor treatment response. Therefore, the aim of this study was to investigate the clinical course of IGB patients and identify factors that are predictive of failure of conservative treatment.

Materials and Methods:

Our study consisted of IGB patients diagnosed between 2010 March and 2016 December who had been followed-up for at least one year. Structured questionnaires and medical records were reviewed to analyse demographic characteristics, lifestyle patterns, blood tests, and imaging studies. We categorized the cases into two groups based on the response to conservative treatment and the need for surgical intervention.

Results:

The most common initial chief symptoms were buttock pains in 24 patients (37.5%). Physical examinations showed the tenderness of ischial tuberosity area in 59 (92.2%) patients, but no specific findings were confirmed in 5 patients (7.8%). 51 patients (79.7%) responded well to the conservative management, 11 patients (17.2%) needed injection, and 2 patients (3.1%) had surgical treatment performed due to continuous recurrence. There was no difference in demographic and blood lab data between the two groups. However, the incidence of inflammatory diseases (response group: 10.3% vs non-response group: 66.7%, p=0.004) was significantly different between the two groups.

Conclusion:

The diagnosis of IGB can be missed due to variations in clinical symptoms, and cautions should be exercised in patients with inflammatory diseases as conservative treatment is less effective in them, leading to chronic progression of IGB.

Chronic High Hamstring Tendinopathy and Sacroiliac Segmental Dysfunction in a Mature Tae Kwon Do Athlete: A Case Study

Objective

This case study describes conservative management of high hamstring tendinopathy in a master's-age tae kwon do athlete.

Clinical Features

A 53-year-old female tae kwon do athlete of 10 years presented after ceasing activities of performance for over a year owing to chronic pain of insidious onset in the left buttock with radiation to the left hip and posterior thigh. The patient's pain was preventing her from being able to perform regular activities of daily living such as brisk walking or sitting. The pain was registered as a 7/10 on the numeric pain scale. Radiographs of the lumbopelvic area were negative. Conservative treatment localized the pain to the left ischial tuberosity. Magnetic resonance imaging showed bilateral trochanteric bursitis and left hamstring tendinopathy.

Intervention and Outcome

Following conservative management with therapeutic ultrasound over the hamstring origin, manual sacroiliac manipulation, and rehabilitation, she had complete resolution of symptoms.

Conclusion

This patient had a combination of pain syndromes including chronic high hamstring tendinopathy and sacroiliac joint dysfunction. There are many other factors that must be taken into consideration, including repetitive trauma of tae kwon do, age, and sex, that play a role in tendon and ligament changes over time. This case demonstrates management of coconditions and comorbidities that can be used in not only the athletic population but many other populations.

Active ankle position sense and single-leg balance in runners versus non-runners

Introduction: Ankle sprain is one of the most common injuries in collegiate athletes, including runners. The purpose of the study was to examine whether runners exhibited compromised ankle stability, ankle position sense, and single-leg balance.Methods: Thirty-seven individuals (21 non-runners and 16 runners) participated in the study. To be included in the runner group, subjects were required to run greater than 150 minutes per week for the past three months. We used the Cumberland Ankle Instability Tool (CAIT) to categorize ankle stability, and we used a dual-axis electronic goniometer to examine active ankle position sense. We examined single-leg balance with the Athletic Single Leg Stability Test of the Biodex Balance System using three different protocols: 1) default setting, 2) no extrinsic visual feedback, and 3) no extrinsic feedback with a cognitive demand.Results: Runners and non-runners had similar ankle stability (CAIT = 26.88 and 26.45 respectively; p = .666). Although runners had significantly larger ankle position errors than non-runners overall (2.56° vs. 1.68°; p = .004), they had better single-leg balance than non-runners without extrinsic visual feedback (Stability Index 1.67 vs. 4.39; p < .001), even with an added cognitive loading (Stability Index 2.18 vs. 4.32; p < .001).Conclusions: For runners, having worse ankle position sense did not compromise ankle stability, nor contribute to single-leg balance deficits. Runners may have established better motor control to maintain their single-leg balance and ankle stability.

Transient osteoporosis: an unusual presentation of hip pain in a trail runner

We present a case of transient osteoporosis of the hip in a 38-year-old recreational trail runner. Shortly after a trail running competition, he developed acute hip pain, functional disability and an antalgic gait. Diagnosis was made with MRI showing bone marrow oedema, plain radiographs demonstrating osseous demineralisation and bone scintigraphy showing uniform radioactive uptake. Treatment included off-loading of the anatomical site for 6 months until symptom resolution, analgaesia, Vitamin D, bisphosphonates and pulsed electromagnetic field therapy. He recovered fully and returned to running activities 8 months after initial presentation. Transient osteoporosis of the hip is rare but benign, self-limiting condition; however, awareness and exact diagnosis are important as runners often present with hip pain and other more serious pathologies such as avascular necrosis or stress fractures need to be excluded.

Five-Year Outcomes and Return to Sport of Runners Undergoing Hip Arthroscopy for Labral Tears With or Without Femoroacetabular Impingement

BACKGROUND

Recent evidence has demonstrated a high rate of return to running after hip arthroscopy for femoroacetabular impingement at short-term follow-up. The midterm outcomes and rates of continued running of these patients are unknown.

PURPOSE

To evaluate midterm rates of return to running and outcomes after hip arthroscopy.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Data were prospectively collected for patients who underwent hip preservation surgery between July 2008 and November 2011. Patients were excluded for preoperative Tönnis osteoarthritis grade ≥2, previous ipsilateral hip conditions or hip surgery, or workers' compensation status. All patients who participated in mid- to long-distance running before their surgery and intended on returning after their operation were considered for inclusion. Preoperative and minimum 5-year postoperative measures for the following patient-reported outcome scores (PROs) were necessary for inclusion in the final cohort: the modified Harris Hip Score, Non-arthritic Hip Score, Hip Outcome Score-Sports Specific Subscale, and visual analog scale (VAS) for pain. All patients were counseled about the risks of continued running after hip arthroscopy.

RESULTS

Sixty patients (62 hips) were eligible for inclusion, of which 50 (83.3%; 52 hips) had minimum 5-year follow-up. There were 10 male hips and 42 female hips. Mean ± SD age at surgery was 32.4 ± 12.4 years (range, 14.9-62.4), and mean body mass index was 22.9 ± 3.2 (range, 17.7-30.1). Latest follow-up was recorded at a mean 69.3 ± 8.5 months (range, 60.0-92.1 months). Level of competition included 39 recreational, 7 high school, 4 collegiate, and 2 professional athletes. There were significant improvements in all PROs and VAS scores preoperatively to latest follow-up. Mean modified Harris Hip Score improved from 67.5 to 88.2; mean Non-arthritic Hip Score, from 65.9 to 88.3; mean Hip Outcome Score-Sports Specific Subscale, from 49.5 to 81.0; and mean VAS, from 5.2 to 1.5. At latest follow-up, patient satisfaction was 8.4. Thirty-nine patients (78.0%, 41 hips) had returned to running postoperatively. When stratified by level of competition, 79% (31 of 39) of recreational, 100% (7 of 7) of high school, 50% (2 of 4) of collegiate, and 50% (1 of 2) of professional athletes returned to running.

CONCLUSION

Hip arthroscopy for all levels of runners is associated with a significant increase in PROs and a low risk of complications. The rate of return to running is moderately high after hip arthroscopy at midterm follow-up. Hip arthroscopy may be considered for runners presenting with symptoms of femoroacetabular impingement that fail nonoperative treatments. Patients should be educated on the rate of return to running over time and the risks of continued running after hip arthroscopy.

Does 3DMR provide equivalent information as 3DCT for the pre-operative evaluation of adult Hip pain conditions of femoroacetabular impingement and Hip dysplasia?

OBJECTIVE:

Femoroacetabular impingement (FAI) and hip dysplasia (HD) are frequently evaluated by isotropic CT (3DCT) for preoperative planning at the expense of radiation. The aim was to determine if isotropic MRI (3DMR) imaging can provide similar quantitative and qualitative morphological information as 3DCT.

METHODS:

25 consecutive patients with a final diagnosis of FAI or HD were retrospectively selected from December 2016-December 2017. Two readers (R1, R2) performed quantitative angular measurements on 3DCT and 3DMR, blinded to the diagnosis and each other's measurements. 3DMR and 3DCT of the hips were qualitatively and independently evaluated by a radiologist (R3), surgeon (R4), and fellow (R5). Interobserver and intermodality comparisons were performed.

RESULTS:

The ICC was good to excellent for all measurements between R1 and R2 (ICC:0.60-0.98) and the majority of intermodality measurements for R1 and R2. Average inter-reader and inter-modality PABAK showed good to excellent agreement for qualitative reads. On CT, all alpha angles (AA) were significantly lower in dysplasia patients than in cam patients (p < 0.05). All lateral center-edge angle (LCEA) were significantly lower in dysplasia than in cam patients (p < 0.05). On MR, AA at 12, 1, and 2 o'clock, and LCEA at center were significantly lower in dysplasia patients than in cam patients (p < 0.05).

CONCLUSION:

3DMR offers similar qualitative and quantitative analysis as 3DCT in adult painful hip conditions.

ADVANCES IN KNOWLEDGE:

3DMR has good potential to replace 3DCT and serve as a one-stop modality for bone and soft tissue characterizations in the pre-operative evaluation of FAI and HD.

Case report: ischial stress fracture non-union in a college football player

Stress fractures are common injuries associated with repetitive high-impact activities, often in high-level athletes and military recruits. Although predominantly occurring in the lower extremities, stress fractures may occur wherever there is a sudden increase in frequency or intensity of activity, thereby overloading the yield point of the local bone environment. Ischial stress fractures are a rarely diagnosed cause of pain around the hip and pelvis. Often, patients present with buttock pain with activity, which can be misdiagnosed as proximal hamstring tendonitis or avulsion. Here, we report a case of a college football player who was diagnosed with an ischial stress fracture which went on to symptomatic non-union after extensive conservative management. We treated his ischial non-union with open reduction internal fixation utilizing a tension band plate and screws. This interesting case highlights an uncommon cause of the relatively common presentation of posterior hip pain and describes our technique for addressing a stress fracture non-union in the ischium.

No difference in prevalence of spine and hip pain in young Elite skiers

PURPOSE

To investigate the prevalence between back and hip pain in young Elite skiers.

METHODS

Sample group (n = 102), consisted of young Elite skiers (n = 75) and age-matched non-athletes (n = 27), all completed a three-part back and hip pain questionnaire, Oswestry Disability Index and EuroQoL to evaluate general health, activity level, back and hip pain prevalence.

RESULTS

No significant differences were shown for lifetime prevalence of back pain in the skiers (50%) compared with controls (44%) (n.s.). Duration of back pain for the skiers showed (30%) > 1 year, whilst (46%) > 5 years. A significant difference was shown with increased Visual Analogue Scale back pain levels for skiers 5.3 (SD 3.1) compared with controls 2.4 (SD 1.9, p = 0.025). No significant differences were shown for lifetime prevalence of hip pain in skiers (21%) compared with controls (8%) (n.s.).

CONCLUSION

Young Elite skiers are shown not to have increased lifetime prevalence for back and hip pain compared with a non-athletic control group.

LEVEL OF EVIDENCE

II.

Greater trochanteric pain syndrome and gluteus medius and minimus tendinosis: nonsurgical treatment

Greater trochanteric pain syndrome (GTPS) affects 10–25% of people in developed countries. The underlying etiology for GTPS is most commonly the tendinosis or a tendon tear of the gluteus medius, minimus or both at the greater trochanter; the inflammation of the tendon is not a major feature. We critically evaluated conservative treatment, for which we reviewed 76 publications, grading them according to four levels of evidence. We identified a wide variety of conservative treatment options: home therapy (insoles, walking sticks/crutches, orthotic devices, stretching exercises and preventive measures); physiotherapy (massage and stretching exercises); infiltrations (corticosteroids and local anesthetics); image-guided infiltrations (fluoroscopy and ultrasound); shockwave therapy; platelet-rich plasma injection; and drug therapy. Severe complications associated with infiltrations are extremely rare, as are those associated with shockwave therapy. The most effective treatments were infiltrations with corticosteroids and shockwave therapy. We propose a graded treatment schedule for patients with GTPS.

Sports Injuries about the Hip: What the Radiologist Should Know

Injuries of the hip and surrounding structures represent a complex and commonly encountered scenario in athletes, with improper diagnosis serving as a cause of delayed return to play or progression to a more serious injury. As such, radiologists play an essential role in guiding management of athletic injuries. Familiarity with hip anatomy and the advantages and limitations of various imaging modalities is of paramount importance for accurate and timely diagnosis. Magnetic resonance (MR) imaging is often the modality of choice for evaluating many of the injuries discussed, although preliminary evaluation with conventional radiography and use of other imaging modalities such as ultrasonography (US), computed tomography, and bone scintigraphy may be supplementary or preferred in certain situations. Stress fractures, thigh splints, and posterior hip dislocations are important structural injuries to consider in the athlete, initially imaged with radiographs and often best diagnosed with MR imaging. Apophyseal injuries are particularly important to consider in young athletes and may be acute or related to chronic repetitive microtrauma. Femoroacetabular impingement has been implicated in development of labral tears and cartilage abnormalities. Tear of the ligamentum teres is now recognized as a potential cause of hip pain and instability, best evaluated with MR arthrography. Greater trochanteric pain syndrome encompasses a group of conditions leading to lateral hip pain, with US playing an increasingly important role for both evaluation and image-guided treatment. Muscle injuries and athletic pubalgia are common in athletes. Lastly, snapping hip syndrome and Morel-Lavallée lesions are two less common but nonetheless important considerations. ^©RSNA, 2016.

Wearable embroidered muscle activity sensing device for the human upper leg

Within the last decade, running has become one of the most popular physical activities in the world. Although the benefits of running are numerous, there is a risk of Running Related Injuries (RRIs) of the lower extremities. Electromyography (EMG) techniques have previously been used to study causes of RRIs, but the complexity of this technology limits its use to a laboratory setting. As running is primarily an outdoors activity, this lack of technology acts as a barrier to the study of RRIs in natural environments. This study presents a minimally invasive wearable muscle sensing device consisting of jogging leggings with embroidered surface EMG (sEMG) electrodes capable of recording muscle activity data of the quadriceps group. To test the use of the device, a proof of concept study consisting of N = 2 runners performing a set of 5 km running trials is presented in which the effect of running surfaces on muscle fatigue, a potential cause of RRIs, is evaluated. Results show that muscle fatigue can be analysed from the sEMG data obtained through the wearable device, and that running on soft surfaces (such as sand) may increase the likelihood of suffering from RRIs.

High Rate of Return to Running for Athletes After Hip Arthroscopy for the Treatment of Femoroacetabular Impingement and Capsular Plication

BACKGROUND

Femoroacetabular impingement (FAI) is most commonly diagnosed in athletes who sustain repetitive flexion loading to their hips. No studies to date have focused solely on patients' return-to-running ability after hip arthroscopy.

PURPOSE

To evaluate patients' ability to return to running after hip arthroscopy for FAI and capsular plication.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Clinical data were retrospectively retrieved for 51 consecutive patients with FAI (22 men, 29 women) who had undergone hip arthroscopy for the treatment of FAI and identified themselves as recreational or competitive runners on intake forms. Two-year outcome measures included the modified Harris Hip Score (mHHS) and the Hip Outcome Score Activities of Daily Living (HOS-ADL) and Sport-Specific (HOS-SS) subscales. A postoperative return-to-running survey was used to obtain running-specific information.

RESULTS

Patient age and body mass index (BMI) were a mean (±SD) of 26.3 ± 7.8 years and 23.7 ± 3.3 kg/m², respectively. Before surgery, patients had refrained from running because of pain for a mean of 8.1 ± 5.7 months. After surgery, 48 patients (94%) returned to running at a mean of 8.5 ± 4.2 months. Patients who had discontinued running for more than 8 months before surgery had a longer return-to-running time than did those who had stopped for less than 8 months (10.6 ± 4.2 vs 7.6 ± 4.1 months; P = .01). After 2 years, mean preoperative distance had decreased significantly ( P < .01) from 9.5 ± 6.5 miles per week when healthy to 6.4 ± 5.8 miles postoperatively. Despite decreased mileage, all 2-year outcomes scores improved significantly ( P < .001).

CONCLUSION

Recreational and competitive runners with FAI returned to running 94% of the time at a mean of 8.5 months after hip arthroscopy. However, runners should be counseled before their surgery that they may run fewer miles than when they were pain free. Additionally, patients with a higher BMI and/or longer preoperative lull may have a longer recovery time.

INCIDÊNCIA DE LESÕES EM PRATICANTES DE CORRIDA DE RUA NO MUNICÍPIO DE CRICIÚMA, BRASIL

RESUMO Introdução: Observa-se um pronunciado aumento da popularidade das corridas de rua; consequentemente, há mais adeptos dessa prática. Assim sendo, vários estudos vêm buscando diversas abordagens da modalidade, visando desvendar os mecanismos que a compõem. Objetivo: Verificar a incidência de lesões em praticantes de corrida de rua do município de Criciúma, SC, assim como outros fatores associados, como perfil dos praticantes, características do treinamento e existência de acompanhamento profissional. Métodos: Foi realizado um estudo descritivo transversal com 88 corredores (56 homens e 32 mulheres). Resultados: A média de idade foi 36 anos, sendo que a maioria dos participantes praticava corrida três vezes por semana (55,4%) e, do total da amostra, 43,2% já haviam tido alguma lesão, sendo o joelho (52,6%) o local mais acometido. Entre os que já tinham sofrido lesão, houve forte correlação entre quantidade de lesões e o tempo de prática da modalidade (r = 0,269) e os que percorriam maior distância média diária de treino (r = 0,226). No entanto, os dados demonstraram que o trabalho preventivo não foi eficaz na diminuição de incidência de lesão (r = -0,133). Conclusão: Há uma relação direta entre distância percorrida e lesão, bem como o tempo de prática. A orientação de profissionais não tem influência significativa na redução das lesões, ou seja, muitas lesões podem ser decorrentes do volume e da intensidade dos treinos prescritos ou executados de maneira equivocada, não respeitando o condicionamento físico atual e a individualidade biológica, na perspectiva de superar seus próprios limites de qualquer modo. Ressaltamos a importância de mais estudos que relacionem a progressão de treinamento, lesão e prevenção.

Lesser Trochanter Avulsion Fracture in an Adolescent after Seizure

BACKGROUND

Injury secondary to epileptic seizure is widely documented in the literature. In particular, uncontrolled muscular contractions generated during a seizure can lead to a variety of musculoskeletal injuries.

CASE REPORT

We present the case of a 16-year-old male who presented on two separate occasions after a tonic-clonic seizure with hip pain, an antalgic gait, and marked discomfort on hip flexion. Radiologic investigation revealed an acute isolated fracture of the lesser trochanters. Such fractures in adolescents are normally secondary to athletic injury and in adults are mainly associated with the presence of metastatic bone disease. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: We present this case with its previously undocumented mechanism to highlight the injury to frontline emergency medical teams, create awareness of its presentation, and to discuss its potential mechanism and treatment.

The 5- or 10-km Marikenloop Run: A Prospective Study of the Etiology of Running-Related Injuries in Women

Study Design Prospective cohort. Background The popularity of running events is still growing, particularly among women; however, little is known about the risk factors for running-related injuries in female runners. Objectives The aims of this study were to determine the incidence and characteristics (site and recurrence) of running-related injuries and to identify specific risk factors for running-related injuries among female runners training for a 5- or 10-km race. Methods Four hundred thirty-five women registered for the Marikenloop run of 5 or 10 km were recruited. Follow-up data were collected over 12 weeks using questionnaires, starting 8 weeks before the event and ending 4 weeks after the event. Two orthopaedic tests (navicular drop test and extension of the first metatarsophalangeal joint) were performed in the 8 weeks before the event. Running-related injuries, defined as running-related pain of the lower back and/or the lower extremity that restricted running for at least 1 day, were assessed at 1-, 2-, and 3-month follow-ups. Results Of 417 female runners with follow-up data (96%), 93 runners (22.3%) reported 109 running-related injuries, mainly of the hip/groin, knee, and lower leg. Multivariable Cox regression analysis showed that a weekly training distance of more than 30 km (hazard ratio = 3.28; 95% confidence interval [CI]: 1.23, 8.75) and a previous running injury longer than 12 months prior (hazard ratio = 1.88; 95% CI: 1.03, 3.45) were associated with the occurrence of running-related injuries. Conclusion Hip/groin, knee, and lower-leg injuries were common among female runners. Only weekly training distance (greater than 30 km) and previous running injury (greater than 12 months prior) were associated with running-related injuries in female runners training for a 5- or 10-km event. Level of Evidence Etiology, 2b. J Orthop Sports Phys Ther 2016;46(6):462-470. Epub 26 Apr 2016. doi:10.2519/jospt.2016.6402.

Protocol for evaluating the effects of a therapeutic foot exercise program on injury incidence, foot functionality and biomechanics in long-distance runners: a randomized controlled trial

BACKGROUND

Overall performance, particularly in a very popular sports activity such as running, is typically influenced by the status of the musculoskeletal system and the level of training and conditioning of the biological structures. Any change in the musculoskeletal system's biomechanics, especially in the feet and ankles, will strongly influence the biomechanics of runners, possibly predisposing them to injuries. A thorough understanding of the effects of a therapeutic approach focused on feet biomechanics, on strength and functionality of lower limb muscles will contribute to the adoption of more effective therapeutic and preventive strategies for runners.

METHODS/DESIGN

A randomized, prospective controlled and parallel trial with blind assessment is designed to study the effects of a "ground-up" therapeutic approach focused on the foot-ankle complex as it relates to the incidence of running-related injuries in the lower limbs. One hundred and eleven (111) healthy long-distance runners will be randomly assigned to either a control (CG) or intervention (IG) group. IG runners will participate in a therapeutic exercise protocol for the foot-ankle for 8 weeks, with 1 directly supervised session and 3 remotely supervised sessions per week. After the 8-week period, IG runners will keep exercising for the remaining 10 months of the study, supervised only by web-enabled software three times a week. At baseline, 2 months, 4 months and 12 months, all runners will be assessed for running-related injuries (primary outcome), time for the occurrence of the first injury, foot health and functionality, muscle trophism, intrinsic foot muscle strength, dynamic foot arch strain and lower-limb biomechanics during walking and running (secondary outcomes).

DISCUSSION

This is the first randomized clinical trial protocol to assess the effect of an exercise protocol that was designed specifically for the foot-and-ankle complex on running-related injuries to the lower limbs of long-distance runners. We intend to show that the proposed protocol is an innovative and effective approach to decreasing the incidence of injuries. We also expect a lengthening in the time of occurrence of the first injury, an improvement in foot function, an increase in foot muscle mass and strength and beneficial biomechanical changes while running and walking after a year of exercising.

TRIAL REGISTRATION

Clinicaltrials.gov Identifier NCT02306148 (November 28, 2014) under the name "Effects of Foot Strengthening on the Prevalence of Injuries in Long Distance Runners". Committee of Ethics in Research of the School of Medicine of the University of Sao Paulo (18/03/2015, Protocol # 031/15).

What are the main risk factors for running-related injuries?

BACKGROUND

Despite several studies that have been conducted on running injuries, the risk factors for running-related injuries are still not clear in the literature.

OBJECTIVE

The aim of this study was to systematically review prospective cohort studies that investigated the risk factors for running injuries in general.

DATA SOURCES

We conducted electronic searches without restriction of language on EMBASE (1980 to Dec 2012), PUBMED (1946 to Dec 2012), CINAHL (1988 to Dec 2012) SPORTDiscus (1977 to Dec 2012), Latin American and Caribbean Centre on Health Sciences Information (1985 to Dec 2012) and Scientific Electronic Library Online (1998 to Dec 2012) databases, using subject headings, synonyms, relevant terms and variant spellings for each database.

STUDY SELECTION

Only prospective cohort studies investigating the risk factors for running-related musculoskeletal injuries were included in this review. Two independent reviewers screened each article and, if they did not reach a consensus, a third reviewer decided whether or not the article should be included.

STUDY APPRAISAL AND SYNTHESIS METHODS

Year of publication, type of runners, sample size, definition of running-related musculoskeletal injury, baseline characteristics, reported risk factors and the statistical measurement of risk or protection association were extracted from the articles. A scale adapted by the authors evaluated the risk of bias of the articles.

RESULTS

A total of 11 articles were considered eligible in this systematic review. A total of 4,671 pooled participants were analysed and 60 different predictive factors were investigated. The main risk factor reported was previous injury (last 12 months), reported in 5 of the 8 studies that investigated previous injuries as a risk factor. Only one article met the criteria for random selection of the sample and only six articles included a follow-up of 6 months or more. There was no association between gender and running injuries in most of the studies.

LIMITATIONS

It is possible that eligible articles for this review were published in journals that were not indexed in any of the searched databases. We found a great heterogeneity of statistical methods between studies, which prevented us from performing a meta-analysis.

CONCLUSIONS

The main risk factor identified in this review was previous injury in the last 12 months, although many risk factors had been investigated in the literature. Relatively few prospective studies were identified in this review, reducing the overall ability to detect risk factors. This highlights the need for more, well designed prospective studies in order to fully appreciate the risk factors associated with running.

The effects of isolated ankle strengthening and functional balance training on strength, running mechanics, postural control and injury prevention in novice runners: design of a randomized controlled trial

BACKGROUND

Risk factors have been proposed for running injuries including (a) reduced muscular strength, (b) excessive joint movements and (c) excessive joint moments in the frontal and transverse planes. To date, many running injury prevention programs have focused on a "top down" approach to strengthen the hip musculature in the attempt to reduce movements and moments at the hip, knee, and/or ankle joints. However, running mechanics did not change when hip muscle strength increased. It could be speculated that emphasis should be placed on increasing the strength of the ankle joint for a "ground up" approach. Strengthening of the large and small muscles crossing the ankle joint is assumed to change the force distribution for these muscles and to increase the use of smaller muscles. This would be associated with a reduction of joint and insertion forces, which could have a beneficial effect on injury prevention. However, training of the ankle joint as an injury prevention strategy has not been studied. Ankle strengthening techniques include isolated strengthening or movement-related strengthening such as functional balance training. There is little knowledge about the efficacy of such training programs on strength alteration, gait or injury reduction.

METHODS/DESIGN

Novice runners will be randomly assigned to one of three groups: an isolated ankle strengthening group (strength, n = 40), a functional balance training group (balance, n = 40) or an activity-matched control group (control, n = 40). Isokinetic strength will be measured using a Biodex System 3 dynamometer. Running kinematics and kinetics will be assessed using 3D motion analysis and a force platform. Postural control will be assessed by quantifying the magnitude and temporal structure of the center of pressure trace during single leg stance on a force platform. The change pre- and post-training in isokinetic strength, running mechanics, and postural control variables will be compared following the interventions. Injuries rates will be compared between groups over 6 months.

DISCUSSION

Avoiding injury will allow individuals to enjoy the benefits of participating in aerobic activities and reduce the healthcare costs associated with running injuries.

TRIAL REGISTRATION

Current Controlled Trial NCT01900262.

Hip muscle loads during running at various step rates

STUDY DESIGN

Controlled laboratory study, cross-sectional. Objectives To characterize hip muscle forces and powers during running, and to determine how these quantities change when altering step rate for a given running speed.

BACKGROUND

Hip musculature has been implicated in a variety of running-related injuries and, as such, is often the target of rehabilitation interventions, including resistance exercises and gait retraining. The differential contributions of the hip muscles to the task of running are not well understood, and may be important for recognizing the biomechanical mechanisms of running-related injuries and refining current treatment and prevention strategies.

METHODS

Thirty healthy participants ran at their preferred speed at 3 different step rates: 90%, 100%, and 110% of their preferred step rate. Whole-body kinematics and ground reaction forces were recorded. A 3-D musculoskeletal model was used to estimate muscle forces needed to produce the measured joint accelerations. Forces and powers of each muscle were compared across step-rate conditions.

RESULTS

Peak force produced by the gluteus medius during running was substantially greater than that of any other hip muscle, with the majority of muscles displaying a period of negative work immediately preceding positive work. The higher running step rate led to an increase in hip flexor, hamstring, and hip extensor loading during swing, but, conversely, substantially diminished peak force and work during loading response for several hip muscles, including the gluteal muscles and piriformis.

CONCLUSION

Increasing running step rate for a given running speed heightened hamstring and gluteal muscle loading in late swing, while decreasing stance-phase loading in the gluteal muscles and piriformis. These results may enable clinicians to support and refine current treatment strategies, including exercise prescription and gait retraining for running-related injuries.

Evaluation and treatment of biking and running injuries

Exercise is universally recognized as a key feature for maintaining good health. Likewise, lack of physical activity is a major risk factor for chronic disease and disability, an especially important fact considering our rapidly aging population. Biking and running are frequently recommended as forms of exercise. As more individuals participate in running-related and cycling-related activities, physicians must be increasingly aware of the common injuries encountered in these pursuits. This review focuses on the evaluation and management of common running-related and cycling-related injuries.

Triathlon: running injuries

The running portion of the triathlon represents the final leg of the competition and, by some reports, the most important part in determining a triathlete's overall success. Although most triathletes spend most of their training time on cycling, running injuries are the most common injuries encountered. Common causes of running injuries include overuse, lack of rest, and activities that aggravate biomechanical predisposers of specific injuries. We discuss the running-associated injuries in the hip, knee, lower leg, ankle, and foot of the triathlete, and the causes, presentation, evaluation, and treatment of each.

MRI of radiographically occult ischial apophyseal avulsions

BACKGROUND

Acute avulsions of unossified ischial apophyses in children may go undetected on radiography. Therapy includes rest and rehabilitation; however, substantial displacement may require surgery.

OBJECTIVE

Our purpose is to illustrate the utility of MRI in the detection of these radiographically occult injuries in skeletally immature children.

MATERIALS AND METHODS

This retrospective study of more than 5 years included children with ischial avulsions who were evaluated with both radiography and MRI within 3 weeks of acute injury. Initially, radiographs were reviewed to identify those children with unossified ischial apophyses. Subsequently, their MRI examinations were assessed for physeal disruption, bone/soft tissue edema, periosteal/perichondrial elevation and disruption. Initial and follow-up radiographs (if available) were reviewed. Patient age, symptoms and offending activity were determined from clinical records.

RESULTS

Five children met inclusion criteria. All initial radiographs were normal. MRI showed: edema (n = 5), periosteal elevation (n = 4), periosteal/perichondrial disruption (n = 4), >5.5 mm displacement (n = 0). Follow-up radiographs in two children (2 and 2.5 months from MRI) showed osseous ischial irregularity. The apophyses remained unossified.

CONCLUSIONS

Acute unossified ischial apophyseal avulsions in children may be radiographically undetected. In the setting of correlative clinical symptoms, MRI can be used to identify these injuries and to help direct appropriate therapy.

Prevalência e fatores associados a lesões em corredores amadores de rua do município de Belo Horizonte, MG

INTRODUÇÃO: A prática da corrida de rua tem aumentado nos últimos anos, tanto por sua facilidade quanto pelo baixo custo envolvido. Essa prática, todavia, envolve risco de lesões musculoesqueléticas. OBJETIVO: Verificar a prevalência de lesões osteomioarticulares e analisar os fatores associados em corredores de rua amadores de Belo Horizonte, MG. MÉTODOS: Foi realizado um estudo observacional do tipo transversal. A seleção da amostra foi por conveniência. Participaram da pesquisa 100 atletas amadores com pelo menos três meses de prática de corrida com frequência mínima de duas vezes por semana. Foram coletados os dados referentes à prevalência de lesões e os fatores associados através de um questionário estruturado. RESULTADOS: A prevalência de lesões entre os atletas foi de 40%. Dentre os fatores associados à lesão destacam-se a distância média diária e a variação no volume do treinamento. CONCLUSÃO: A prevalência de lesões em corredores amadores é considerável, apesar de ter sido relatada por menos da metade dos participantes. As características do treinamento podem desencadear lesões e devem ser analisadas com cautela para que a corrida seja realizada de forma segura.

Management of the greater trochanteric pain syndrome: a systematic review

INTRODUCTION

Greater trochanteric pain syndrome (GTPS) is a debilitating condition characterized by lateral hip pain located at or around the greater trochanter.

SOURCE OF DATA

We performed a comprehensive search of Pubmed, Medline, Ovid, Google Scholar and Embase databases, from inception of the database to 20th of June 2011, using a variety of keywords. We identified 52 relevant abstracts of articles published in peer-reviewed journals. Fourteen studies reporting the outcomes of patients undergoing conservative and surgical management of GTPS were selected.

AREAS OF AGREEMENT

Significant pain relief and improved outcomes were observed after conservative and surgical management of GTPS. The modified Coleman methodology score averaged 44.7 (range from 14 to 82), evidencing an overall low-to-moderate quality of the studies. Repetitive low-energy radial shock wave therapy and home training approach provide beneficial effect over months, with almost 80% success rate at 15 months.

AREAS OF CONTROVERSY

Poor available data extracted from small studies do not allow definitive conclusions to be drawn on the best treatment for GTPS.

GROWING POINTS

Further multi-centre prospective studies are necessary to confirm the general validity of the findings reported.

AREAS TIMELY FOR DEVELOPING RESEARCH

Future research and trials should focus on the application and effectiveness of the various conservative modalities for management of GTPS.

CONCLUSION

The effectiveness of the various treatment modalities needs to be tested in carefully conducted randomized controlled trials.

Concurrent criterion-related validity of physical examination tests for hip labral lesions: a systematic review

Hip injuries are prevalent, especially within the athletic population. Of the hip injuries in this population, some 18-55% are lesions to the labrum of the hip. Clinical diagnosis of hip labral lesions is difficult because data on prevalence are varied. In addition, data on the prevalence of internal and external risk factors are absent as are data on the correlation of these risk factors with labral lesions, making it difficult to gauge the diagnostic utility. The mechanism of injury is often unknown or not specific to labral lesions. Internal risk factors may remain hidden to physical therapists because in most jurisdictions, ordering imaging tests is not within their scope of practice. Anterior inguinal pain seems highly sensitive for the diagnosis of patients with labral lesions but can hardly be considered specific; data on other pain-related and mechanical symptoms clearly have little diagnostic utility, making these data collected during the patient history almost irrelevant to diagnosis. By way of a comprehensive literature review and narrative and systematic analysis of the methodological quality of the retrieved diagnostic utility studies, this paper aimed to determine a diagnostic physical examination test or test cluster based on current best evidence for the diagnosis of hip labral lesions. Current best evidence indicates that a negative finding for the flexion-adduction-internal rotation test, the flexion-internal rotation test, the impingement provocation test, the flexion-adduction-axial compression test, the Fitzgerald test, or a combination of these tests provides the clinician with the greatest evidence-based confidence that a hip labral lesion is absent. Currently, research has produced no tests with sufficient specificity to help confidently rule in a diagnosis of hip labral lesion. Suggestions for future research are provided.

Successful rehabilitation of a recreational endurance runner: initial validation for the Bunkie test

This case report details the musculoskeletal evaluation and the successful rehabilitation of a 24-year-old female recreational distance runner who self-referred to physical therapy with an acute bout of low back pain (LBP). Her LBP was provoked during each distance run. The patient's musculoskeletal evaluation revealed core weakness, especially on the left. A recently reported functional test, the Bunkie test, was administered as part of the physical evaluation. The scores from the Bunkie test correlated with other quantitative and qualitative findings. A therapeutic exercise program emphasizing core stabilization was prescribed. The patient was able to shortly return to running pain-free.