Diagnosis and Treatment of Hip Girdle Pain in the Athlete

PM R 8 (2016) S45-S60

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Advanced Sports Medicine Concepts and Controversies

Diagnosis and Treatment of Hip Girdle Pain in the Athlete Heidi Prather, DO, Abby Cheng, MD

Abstract Evaluation of an athlete’s report of “hip pain” is challenging. Many conditions involving the pelvic girdle can present with overlapping pain distributions, and athletes often may have coexisting disorders. Appropriate evaluation requires thorough, systematic consideration of intra-articular hip disease, extra-articular local causes of hip pain, and referred pain from other musculoskeletal or even visceral sources. Although our understanding of intra-articular hip disorders has been greatly enhanced in recent decades through advances in hip arthroscopy, gaps still exist in our understanding of appropriate treatment, including effective nonsurgical protocols and when to consider surgical intervention. For instance, we have a better understanding of hip dysfunction related to structural changes that occur prior to the onset of arthritis, but we are also learning that correction of the structural changes does not always guarantee a correction of dysfunction and pain. Furthermore, athletes need instruction and guidance in retraining appropriate movement patterns after a surgical intervention. Risk stratification regarding which athletes need surgical intervention and what their needs are after specific surgical procedures remain undefined. In this review we will describe the differential diagnosis of hip and pelvic girdle pain in the athlete and then discuss how to use a history, physical examination, and appropriate imaging and diagnostic injections to arrive at a proper diagnosis. Lastly, a brief discussion is included of key concepts and controversies involved in treating some of the most common hip disorders experienced by athletes.

Introduction Hip girdle pain is experienced by athletes of all ages and activity levels. Cutting and other movements requiring frequent and forceful acceleration and deceleration put athletes at particularly high risk of sustaining hip and other pelvic girdle injuries. The complex anatomy and biomechanics of the hip create diagnostic challenges when evaluating an athlete with hip pain. Often the first step in diagnosing the cause of hip pain is to determine whether the athlete has an intra-articular versus an extra-articular disorder or a combination of both. Intra-articular disorders affect structures inside the joint capsule such as the articular cartilage, acetabular labrum, acetabulum, and proximal femur, whereas extra-articular disorders involve bone and soft tissue structures outside the hip joint capsule. The differential diagnosis of hip pain also includes referred sources such as the lumbar spine, pelvic girdle, and visceral conditions of the abdomen and pelvis. Not only do the pain distributions of many of these conditions overlap, but multiple conditions frequently coexist because of force transmission across the hip, pelvic girdle, and spine during movement [1,2].

Even after identifying the cause of a patient’s hip pain, large knowledge gaps still exist regarding optimal management for many intra-articular hip disorders. For example, nonoperative treatment protocols for conditions such as femoroacetabular impingement (FAI) and developmental dysplasia of the hip (DDH) with or without acetabular labral tears continue to evolve. The purpose of this review is to identify the challenges involved in establishing the cause of hip pain, summarize local and referred causes of pelvic girdle pain, provide a clinical approach to the athlete with hip pain, and discuss controversies and nonsurgical treatment options for common local hip disorders. For this descriptive review, we selected literature pertaining to 3 different categories: 1. History and physical examination of the hip 2. Treatment options for athletes with hip pain 3. Discussion of effectiveness of surgical and nonsurgical treatment options We have experience in the review of such literature, including prospective, descriptive, and peer-reviewed publications regarding clinical presentations of athletes,

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asymptomatic control subjects, and symptomatic persons with hip disorders. The senior author (HP) also has been involved in national and international multidisciplinary research cooperatives organized to promote the study of people with prearthritic hip disorders. The literature presented here is descriptive and based on these experiences. Challenges of Evaluating Hip Pain Historically, the distribution of pain related to intraarticular hip disorders was thought to be isolated to the groin and anterior thigh. Whereas the groin is indeed the most common location of pain, multiple studies have described intra-articular hip pain as including distributions to the lateral thigh, posterior pelvis, low back, knee, and lower leg. In patients with symptomatic femoroacetabular impingement requiring surgical intervention, Clohisy and colleagues [3] reported that 88% had groin pain, 67% had lateral hip pain, 35% had anterior thigh pain, 29% had buttock pain, 27% had knee pain, and 23% had low back pain. Patients requiring surgery for symptomatic developmental hip dysplasia presented with a similar prevalence of these pain distributions [4]. Patients with painful acetabular labral tears with and without hip deformity have been described as presenting with a “C” sign in which the patient wraps his/her index finger over the anterior hip and thumb over the posterior trochanteric area to indicate the multiple painful regions [5]. In one study, 47% of patients undergoing surgery for hip osteoarthritis (OA) experienced anterior shin pain and 29% experienced calf pain thought to be related to saphenous nerve referred pain [6]. Because of the variety of pain referral patterns from intra-articular hip conditions, it is not surprising that pain arising from the hip joint has overlapping distributions with pain arising from other structures such as the lumbar spine and extra-articular pelvic girdle. Low back pain with radiculopathy, facet-mediated pain, and sacroiliac (SI) joint pain commonly present as posterior pelvis pain with radiation, in some cases, into the lateral hip and/or groin [7,8]. Intervertebral disk disorders can produce pain in the buttocks, groin, hip, and lower extremities [9], and noxious stimulation of the interspinous ligament and paravertebral muscles can refer pain to the posterior pelvis and lower extremity [10,11]. Piriformis syndrome and greater trochanteric pain syndrome can also present with pain in the posterior pelvis, lateral hip, and thigh [12]. This significant overlap in pain distributions for so many disorders is likely related to the overlap in innervations of these structures. The anterior hip joint capsule is innervated by the obturator and femoral nerves (L2-L4), and the posterior capsule is innervated by the sciatic and superior gluteal nerves (L4-S1) [13]. The nerve roots involved in hip innervation also provide sensation to

essentially all lumbar spine structures, the SI joint, and the lower extremity. Because the variety of pain presentations from intraarticular hip disease overlaps with pain patterns attributed to so many other conditions, the clinician must be careful to consider hip conditions in the differential diagnosis for an athlete experiencing almost any pattern of lower body pain, especially if the athlete is not improving as expected with traditional management of the initial diagnosis. Differential Diagnosis of Hip Pain The differential diagnosis for hip pain in an athlete is extensive and spans multiple medical specialties. Potential causes include intra-articular sources directly from the hip joint, extra-articular structures of the hip girdle, and referred sources from both the lumbopelvic region and from visceral structures of the abdomen and pelvis. To accurately diagnose the cause of an athlete’s hip pain, the clinician must first be aware of all the possible causes. An extensive differential diagnosis is provided in Table 1, and in this section we review some of the more common causes of hip pain observed in athletes. Intra-Articular Sources Intra-articular hip disease affects structures inside the joint capsule, including the articular cartilage, acetabular labrum, ligamentum teres, synovium, acetabulum, and femoral head and neck. Disorders can be caused by congenital, chronic overuse, acute traumatic, inflammatory, infectious, or malignant disease, either in isolation or in combination with each other. Prearthritic hip disorders are common intra-articular sources of pain in athletes and include hip deformities (FAI and DDH) with and without acetabular labral tears. These conditions need to be identified because without proper management, patients have an increased risk of the development of chronic pain syndromes and early articular cartilage degeneration. Disorders of Skeletally Immature Patients Two notable conditions that occur exclusively in skeletally immature patients are Legg-Calve ´- Perthes disease (LCPD) and slipped capital femoral epiphysis (SCFE). LCPD is osteonecrosis of the femoral head epiphysis and occurs in children and young adolescents. LCPD usually occurs in children aged 4-10 years. The cause is thought to be from repetitive microvascular trauma to the femoral head [14]. The condition is more common in boys [15,16] and in hyperactive children [14]. In contrast, SCFE is displacement of the femur at the femoral head epiphysis. SCFE is most common in the adolescent period (ie, in boys aged 10-16 years and in girls aged 12-14 years). Males have

H. Prather, A. Cheng / PM R 8 (2016) S45-S60 Table 1 Differential diagnosis of hip pain

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Table 1 (continued )

Intra-articular sources Prearthritic and arthritic causes Femoroacetabular impingement Developmental hip dysplasia Acetabular labral tear Chondrosis Osteoarthritis Disease of bone and vascular integrity Legg-Calve ´-Perthes disease Slipped capital femoral epiphysis Osteochondritis dissecans Femoral neck stress fracture Avascular necrosis of the femoral head Traumatic causes Traumatic fracture Hip dislocation/subluxation Ligamentum teres tear Other causes Synovitis/inflammatory arthropathy Tumor Infection Extra-articular sources Muscle strain/tendonitis/tendinopathy/incomplete and complete tears Rectus abdominis muscle Iliopsoas muscle Rectus femoris muscle Adductor muscles Gluteus medius and minimus muscles Piriformis muscle Proximal hamstring muscles Ligament injury Iliofemoral ligament sprain Bursitis Greater trochanteric bursae Iliopsoas bursa Hamstring bursa Fracture Pubic ramus stress fracture Apophyseal avulsion fractures Thigh compartment syndrome Hip-specific conditions Greater trochanteric pain syndrome Snapping hip syndrome Sports hernia/pubalgia Osteitis pubis Pubic ramus stress fracture Apophyseal avulsion fracture Referred pain from disease outside the hip Facet joint abnormalities Lumbosacral radiculopathy Posterior pelvic girdle (Including sacroiliac joint dysfunction) Pelvic floor dysfunction Peripheral nerve entrapment Superior and inferior gluteal nerves Obturator nerve Iliohypogastric nerve Lateral femoral cutaneous nerve Pudendal nerve Ilioinguinal nerve Genitofemoral nerve Nonmusculoskeletal sources Gastrointestinal Inguinal/femoral hernia (continued on next column)

Appendicitis Inflammatory bowel disease Diverticulitis Lymphadenitis Genitourinary Urinary tract infection Prostatitis Nephrolithiasis Pelvic inflammatory disease Ovarian cysts Ectopic pregnancy Adapted from Prather [69].

a 2.4 times greater risk of experiencing SCFE compared with females. Technically a Salter-Harris type I fracture, the femoral head remains in the acetabulum while the remainder of the femur shifts anteriorly and rotates externally. SCFE is the most common hip disorder in adolescents and can be associated with endocrine disorders [17]. It tends to occur around the time of puberty and is more common in boys and obese children [18]. When untreated, SCFE can progress and compromise the vascular supply of the femoral head. Both LCPD and SCFE can occur bilaterally, and in severe cases both can result in avascular necrosis (AVN). Femoral Neck Stress Fracture Femoral neck stress fractures (FNSFs) account for less than 10% of all stress fractures, but they account for a disproportionately high rate of morbidity because they have a high rate of nonunion and AVN [19,20]. FNSFs most commonly occur in runners and military personnel, especially after a sudden increase in training intensity or duration. FNSFs are more common in females and almost exclusively occur in skeletally mature patients [21-24]. Femoroacetabular Impingement FAI is a hip deformity that not uncommonly becomes symptomatic in athletes. It is a bony structural deformity consisting of extra bone on the acetabulum or proximal femur. Up to 30% of an asymptomatic population has been found to have radiographic evidence of FAI [25]. When FAI is symptomatic, athletes experience pain related to the abutment of the proximal femur on the acetabulum, typically at end range of motion (ROM) and during loading of the joint. When untreated, FAI can predispose to chronic pain and degenerative changes such as acetabular labral tears, chondrosis, and early OA. Three types of FAI have been identified: cam, pincer, and mixed. Cam impingement, commonly called a “pistol grip deformity,” describes extra bulkiness along the femoral head-neck contour. The cause of cam deformity is still not well understood. One theory is that cam FAI is caused by abnormal skeletal development

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due to intense femoral loading from participation in high-impact sports during adolescence [26-28]. A second theory is that cam FAI represents subclinical SCFE deformities. Traditionally, symptomatic cam-type FAI has been thought to be most common in young, active males [29-31], but experience from clinical practice suggests that this gender difference may no longer be true. Perhaps with the increased participation of girls in youth sports in recent decades, the gender disparity is closing. Updated epidemiologic studies need to be performed. Pincer impingement occurs when a normal femoral neck contacts extra overhang of the anterosuperior acetabulum. Similar to cam deformities, pincer-type FAI has a documented but not well understood gender disparity. Pincer deformities are commonly associated with acetabular retroversion, which is more common in males, but for unclear reasons, pincer-type FAI is more common in middle-aged women. Finally, mixed impingement is a combination of both cam and pincer deformities and is currently reported as more common in males [32,33]. Likely because of increased awareness of how to properly diagnose FAI, the reported relative prevalence of mixed-type FAI is evolving. In a 2009 study by Allen et al [34], 42% of hips with cam deformities also had a pincer deformity. In a 2011 study, Byrd and Jones [35] identified 159 cam, 31 combined, and 10 pincer lesions. In general, athletes’ presentations with hip pain from FAI differ by gender. Females with symptomatic FAI tend to experience hip pain and even FAI-related labral tears associated with more subtle deformities than are required for males to become symptomatic [32,36]. Hetsroni et al [36] theorize that this phenomenon may be due to females’ weaker hip stabilizing muscles that result in increased force through the hip joint or females’ increased soft tissue laxity, allowing greater ROM and frequent contact of the proximal femur and acetabulum [36]. Developmental Dysplasia of the Hip Contrary to pincer-type FAI in which the hip joint is characterized by overcoverage of the acetabulum, DDH is a structural deformity term used to describe insufficient anterolateral coverage of the femoral head by the acetabulum. DDH is also characterized by superolateral inclination of the articular surface and a lateral hip joint center [17]. DDH causes damage to the hip joint because inadequate coverage of the femoral head results in excessive loading of the existing acetabular socket and predisposes to degeneration of the cartilage and eventual OA. DDH screening is routinely performed in newborns, but the diagnosis is also frequently made during the workup of hip pain in adolescent and young adult athletes. It is not well understood why some patients do not present with clinical signs or symptoms of DDH until young

adulthood. In fact, although risk factors have been identified, the cause of DDH is still unclear. It is possible that DDH diagnosed in infancy is a more severe form or even a separate entity than adult-diagnosed DDH. This theory is supported by differences in demographics between the 2 populations: DDH is more common in females than in males, but the gender difference is narrower in the adult-diagnosed DDH presentation [37]. Another gender difference that is clinically relevant is that subsequent degenerative joint-space narrowing from DDH is more severe in females than in males [38]. Acetabular Labral Tear The acetabular labrum is a fibrocartilage ring that surrounds the rim of the acetabulum, seals the hip joint, and increases the surface contact area of the joint. It provides increased stability of the hip and minimizes forces experienced by the articular surfaces. The anterior part of the labrum is thinnest in the crosssectional area and is most susceptible to injury. Trauma to the labrum from abnormal contact between the femoral neck and acetabulum can result in a labral tear. Only the outer one third of the labrum has an adequate vascular supply, and thus tears do not heal well spontaneously. At the same time, because the labrum is densely innervated, especially in the anterosuperior quadrant, labral damage can be very painful. Tears can be caused by either one large force through the hip at end ROM or by repetitive microtrauma. People with bony hip deformities such as FAI and DDH are at higher risk for repetitive labral trauma than are those with structurally normal hips. Labral tears can cause pain, joint locking or catching, limitations in athletes’ activities, and early onset joint degeneration. Of note, females tend to present with smaller labral tears compared with males, but these small tears can still result in significant pain and dysfunction [39]. Dancers represent a group of athletes who benefit from specific expertise regarding hip disorders. In contrast to most athletes, labral tears in dancers are more often found in the setting of structurally normal hips, compared with the usual association with bony deformities such as FAI and DDH. This phenomenon is thought to occur because dancers stress their hip joints repeatedly at extreme ranges of motion. Even without pre-existing bony deformity, the acetabular labrum experiences abnormal forces. Also, because of the positions practiced by dancers, labral tears in this population occur more often in the superior and posterosuperior regions rather than in the anterior and anterosuperior regions as in other athletes [40]. Hip Avascular Necrosis Hip AVN is necrosis of the femoral head as a result of disruption of its blood supply. Hip AVN is an end-stage degenerative disorder. Athletes are at risk for multiple injuries such as trauma, LCPD, SCFE, and FNSFs, all of

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which can predispose to AVN if they are not properly treated. Corticosteroid use, excessive alcohol use, and blood dyscrasias also increase an athlete’s risk for AVN. Deep sea divers who are exposed to extreme barometric pressures are at higher risk as well [17]. Hip Osteoarthritis Hip OA is degeneration of the hip joint articular cartilage, subchondral bone, and joint margins. Up to 80% of cases of hip OA are now thought to be a result of predisposing prearthritic conditions such as trauma, LCPD, SCFE, FAI, DDH, labral tears, AVN, chondral injury, inflammatory arthritis, and infection [17]. A unique and challenging population in sports medicine is young and middle-aged patients who still wish to be active but have had a long-standing pre-existing hip condition. A rare disorder, adhesive capsulitis of the hip, can present with symptoms and ROM limitations identical to those of hip OA. Radiographs may differentiate the 2 conditions, because no or little hip arthritis will be noted in patients with adhesive capsulitis. At the time of this review, the literature contains 13 reports of this disorder; however, some of these reports describe concomitant hip OA and deformity, bringing the diagnosis into question [41]. Hip adhesive capsulitis is diagnosed when ROM is limited in all planes of motion with the patient in a state of general anesthesia. Extra-Articular Sources Extra-articular causes of hip pain include muscle strains, tendinopathy, bursitis, and other soft tissue disorders. These conditions can closely mimic intraarticular conditions at clinical presentation, but their management is distinctly different. In this section we will review common extra-articular causes of hip pain organized by their most common pain distributions. Anterior Pelvis and Groin Pain Pubic Symphysis Disorders. Pubic symphysis pain in the athlete is most commonly due to direct trauma, repetitive overload, and/or instability. These conditions are especially predominant in sports requiring repetitive and forceful rotation, kicking, and overuse of the adductor and the rectus abdominis muscles. Pubic symphysitis is the initial inflammatory response from chronically increased stress to the joint and its corresponding muscle insertions. When untreated, pubic symphysitis can progress to a bony stress reaction, fracture, and/or degenerative osteosclerosis, termed osteitis pubis. Athletes at particular risk of the development of osteitis pubis include those with coexisting trauma, pregnancy, rheumatologic disorders, and infection of the pubic symphysis [17]. Athletic Pubalgia/Sports Hernia. Athletic pubalgia, also called a sports hernia, is an injury to the lower

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abdominal wall. Although the mechanism of this injury is not fully understood, athletic pubalgia is thought to potentially be the result of a hyperextension injury of the rectus abdominis insertion at the pubic symphysis, or alternatively an occult nonvisualized hernia of the posterior inguinal wall. “Gilmore groin” is a subset of athletic pubalgia and describes a tear in the external oblique aponeurosis and conjoint tendon. Athletes who participate in sports that require repetitive rotation of the upper leg and torso, such as ice hockey, soccer, and rugby, are at particularly high risk of this injury. Other risk factors for athletic pubalgia include shearing at the pubic symphysis from repetitive trunk hyperextension and thigh hyperabduction, in addition to muscle imbalance between strong proximal thigh muscles and relatively weaker abdominal muscles [42]. Adductor Strains. Adductor strains are the most common cause of groin pain in athletes [43]. They occur in sports requiring strong eccentric contraction of the adductors, such as soccer and hockey. Injury to this muscle group is particularly detrimental to athletic performance because, along with the lower abdominals, the adductor muscles contribute to stabilization of the pelvis and lower extremity during closed-chain activities. Risk factors for adductor strains include adductor weakness, abductor-adductor imbalance, and decreased hip ROM. Of the 6 muscles in the adductor group, the adductor longus muscle is most commonly strained. It has poor mechanical advantage and a low tendon-to-muscle ratio at its origin on the pubis, which is thought to predispose it to injury [17]. Iliopsoas Muscle Tendon Complex Disorders and Internal Snapping Hip. Because the iliopsoas is the primary hip flexor essential to providing functional stability to the hip, pelvis, and spine, disease of the iliopsoas muscle tendon complex can be either the cause or result of compensatory movement patterns. Disease of the iliopsoas muscle itself often manifests as anterior hip pain during concentric or eccentric contraction of the hip flexors. Because unilateral iliopsoas contraction facilitates lateral lumbar flexion and hip external rotation, iliopsoas disorders are also associated with low back pain. Sports that require repeated and forceful hip flexion and adduction are especially painful, such as uphill running and attempts of a runner to lengthen his or her stride. When iliopsoas disorders result from compensatory guarding for a primary spine or intra-articular hip disorder, increased muscle activation can lead to cumulative tendon overload and shortened muscle length. As a result, the iliopsoas can become painful when stretched during hip extension. Conversely, inefficient movement patterns and suboptimal posture such as excessive anterior pelvic tilt can require the iliopsoas to activate in an overlengthened position and increase the

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likelihood that the muscle will not be able to perform efficiently. In the acute setting, athletes can experience iliopsoas bursitis at the insertion site, and when untreated, tendinosis can develop. Repetitive overuse also can predispose to muscle tears or avulsions, although these injuries more often occur as a result of an acute trauma [17]. Snapping hip syndrome, also called “coxa saltans,” describes conditions in which an audible or palpable snap is appreciated originating from around the hip joint, most often during return to full extension of the hip. The condition can be asymptomatic but more frequently causes pain in athletes who repeatedly perform hip flexion, external rotation, and abduction to end hip ROM, such as dancers, soccer players, weight lifters, and runners [44,45]. Snapping hip syndrome is divided into intra-articular, internal, and external causes. Internal snapping hip is attributed to catching of the iliopsoas tendon on the iliopectineal prominence, femoral head, lesser trochanter, or paralabral cysts. Although some studies have suggested that a thickened iliopsoas tendon contributes to internal snapping hip, usually a snapping iliopsoas tendon is structurally normal but may not be activating at its optimal length. Internal snapping hip is likely a manifestation of chronic iliopsoas dysfunction [17]. The rate of coexisting internal snapping hip and acetabular labral tears is also high, possibly because similar movement patterns predispose to both conditions or because mechanical compensation for one disorder predisposes to the other [46]. Lateral Hip and Thigh Pain Whereas lateral hip pain is most commonly thought to arise from disease of structures lateral to the hip joint, it is important to recognize that intra-articular hip disorders and referred pain from other extra-articular sources such as the sacroiliac joint (SIJ) or lumbar radiculopathy can also present as lateral hip pain. In this section we will describe 2 local sources of lateral hip and thigh pain. Greater Trochanteric Pain Syndrome. In the past, essentially all lateral hip pain manifesting with tenderness to palpation over the greater trochanter was diagnosed as greater trochanteric bursitis. More recently, studies have shown that chronic or recurrent pain predominantly located over the greater trochanter can be associated with disease of a number of different soft tissue structures, and thus “greater trochanteric pain syndrome” (GTPS) is a more appropriate name for this condition. GTPS is more common in middle-aged athletes and in females, possibly because the greater pelvic width-tofemoral length ratio of women unfavorably alters forces created by the gluteus medius muscle and iliotibial band (ITB). Before the diagnosis of isolated GTPS can be made, other conditions such as coexisting lumbar

radiculopathy, intra-articular hip disease, and bony stress reaction or fracture must be ruled out. The cause of GTPS seems to be excessive shearing of the peritrochanteric soft tissue structures as a result of hip abductor weakness or altered gait mechanics. Damage likely occurs in a continuum. Biomechanical dysfunction can lead to tissue overload and initial bursitis of the subgluteus medius and subgluteus maximus bursae. Without correction of these faulty movement patterns and muscle strength and length imbalances, bursitis can evolve into gluteus medius and minimus tendinopathy, enthesopathy, tendon thinning, and eventual microtears and macrotears at the muscle-tendon junctions [47]. Conditions that commonly coexist with GTPS include pes planus, ITB friction syndrome, amputation, obesity, and degenerative joint disease of the hip, spine, and knee [17]. External Snapping Hip. External snapping hip is the presence of auditory or palpable snapping originating lateral to the hip joint. It is the most common type of snapping hip and is due to transient catching of the gluteus maximus tendon or ITB on the greater trochanter as the hip moves between flexion and extension. This disorder is commonly associated with a short ITB and is likely another manifestation of the same biomechanical dysfunction that can lead to GTPS. Posterior Pelvic Pain Posterior pelvic girdle pain is defined as pain between the posterior iliac crests and the gluteal fold that is not from a referred source and is reproducible on specific clinical tests designed to evaluate for posterior pelvic girdle disease [48]. A thorough discussion of how to differentiate among and treat the various causes of posterior pelvic pain is beyond the scope of this review, but the clinician should be aware of local posterior pelvic pain sources when evaluating for an intraarticular hip problem that may refer pain to the posterior pelvis. Pain in this region is often seen in the context of trauma, arthritis, biomechanical dysfunction, and pregnancy. Posterior pelvic pain is commonly assumed to arise from the intra-articular SIJ, and sports that require repeated single leg stance with torsion put athletes at high risk for SIJ dysfunction. These sports include skating, racket sports, rowing, and bowling. However, other sources of posterior pelvic pain include the SIJ ligaments, sacral stress fracture, muscles of the pelvic floor such as the piriformis and obturator internus, sciatic nerve impingement at the level of the piriformis muscle (ie, piriformis syndrome), extra-articular hip impingement between the lesser trochanter and ischial tuberosity (ie, ischiofemoral impingement), and myotendinous disease of the hamstring muscles. Water skiers, sprinters, middle distance runners, and contact sport athletes are at increased risk of hamstring injuries.

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Referred Sources Referred causes of hip girdle pain will not be discussed in depth in this review, but these disorders should be considered in the differential diagnosis of an athlete presenting with a report of hip pain. Again, remember that many of these conditions may also coexist with and contribute to local hip disease. Perhaps the most common musculoskeletal cause of pain referred to the hip is neurogenic pain resulting from lumbar spine disease and nerve root compression. Because muscles of the pelvic floor contribute to hip stability, dysfunction of these muscles can also result in hip pain. Patients presenting with pelvic floor dysfunction may experience changes in bowel, bladder, and sexual function as well, and the clinician should be careful to ask specifically about the presence of these symptoms. Additionally, the clinician must consider the possibility that gastrointestinal or genitourinary disease is causing referred pain that is mistakenly attributed by the athlete to a sports injury. Determining the Cause of Hip Pain Given the overwhelming differential diagnosis for hip pain, a careful, directed history and physical examination are essential to narrowing the diagnostic possibilities and judiciously choosing necessary imaging and other tests. In this section we will review a systematic approach to evaluating an athlete who presents with hip pain. History Clues From Age, Pain Description, and Associated Symptoms Athletes presenting with hip pain are at risk for certain disorders based on age, repetitive movement, and joint stresses. Pediatric and adolescent athletes presenting with hip pain are more likely to have extraarticular apophyseal injuries or intra-articular disease such as LCPD and SCFE. Adults with similar histories are at higher risk for musculotendinous disease and degenerative OA, respectively. An athlete’s mechanism of injury (if any), progression and severity of the pain, exacerbating and alleviating factors, and pain quality also provide valuable clues to underlying disease. Acute-onset pain with muscle contraction or stretching, possibly accompanied by an audible pop, is more likely to have a musculotendinous cause (or an apophyseal cause in adolescents), whereas acute-onset pain after a collision is more suspicious for a fracture or dislocation. Athletes with poor bone health can sustain fractures even from seemingly minor trauma. Burning pain is more likely neuropathic, whereas dull, achy, and sometimes insidious-onset pain that worsens with activity is a common description of intra-articular

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pain. Pain from intra-articular labral tears and/or FAI can also worsen with prolonged sitting, standing, and lying supine while trying to sleep, in addition to causing episodes of sharp pain with kicking and pivoting [49]. Dull pain that worsens with weight bearing and is associated with a recent increase in training intensity or change in training regimen is also typical of femoral, pelvic, and sacral stress fractures. Pain that worsens with increased intra-abdominal pressure such as from coughing, sneezing, and explosive movements like sprinting and kicking is more likely from an abdominal wall defect or referred from an intra-abdominal or intervertebral source. Pain of a degree of severity that prevents weight bearing is typical of unstable SCFE, AVN, or an FNSF that has progressed. Associated symptoms provide clues to the source of pain and dysfunction. Intra-articular disorders such as labral tears and loose bodies can result in mechanical symptoms such as clicking, locking, and popping. Hip snapping can be a result of intra-articular, internal, or external snapping hip, as previously described. Athletes with FAI, especially dancers and gymnasts, may report “stiff hips” and poor ROM despite aggressive stretching efforts. Red flag symptoms such as progressive weakness, saddle anesthesia, incontinence or sexual dysfunction, night-time fevers and sweats, and unintentional weight loss should prompt a more aggressive plan for evaluation of serious conditions. Clues From the Distribution of Pain Despite overlapping pain distributions of hip, spine, and other pelvic disorders, pain distribution can be somewhat helpful in narrowing the diagnosis. Anterior groin pain is the most common location of pain from intra-articular disorders but also can be due to extraarticular disease such as pubic ramus stress fractures, disorders of the pubic symphysis, and adductor or anterior abdominal wall injury. Radiculopathy from high lumbar nerve roots also can refer pain to the anterior groin. Lateral groin pain can still be associated with intraarticular hip disorders, but in isolation it is more frequently associated with extra-articular conditions such as GTPS, ITB dysfunction, and lumbar radiculopathy from the L4-L5 nerve roots. GTPS is commonly associated with lateral hip pain when sleeping on the affected side, climbing stairs, crossing the affected leg, and weight bearing on the affected limb. Both ITB and lumbar disease can manifest as pain radiating down the lateral thigh to the knee. Patients with a labral tear and/or FAI sometimes present with the “C sign,” in which the patient cups his or her hand in a “C” shape around the anterior groin and lateral hip and pelvis to communicate that all these areas are painful [50]. Posterior pelvic pain can be due to local disease such as SIJ dysfunction, but intra-articular hip disease can also manifest with pain in this region. In descriptive

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studies, 29% of patients with FAI, 17% with DDH, and up to 38% with isolated acetabular labral tears reported posterior pelvic pain upon presentation [3,4,49]. Of course, referred pain from lumbar spine disease needs to be ruled out as well. Further, pain related to SIJ dysfunction occasionally can radiate past the knee, and thus eliciting this piece of history alone does not definitively distinguish between lumbar and SIJ dysfunction. Physical Examination Because of the high prevalence of coexisting disorders and overlapping pain distributions, it is important to perform a thorough physical examination of the hip, pelvis, and lumbosacral region, including inspection, palpation, ROM, neurovascular examination, and provocative testing. Careful attention should be directed to any asymmetry between sides. The examination should be somewhat tailored based on the patient’s history, and during the examination, an attempt should be made to reproduce exacerbating and alleviating maneuvers elicited during the history. Table 2 lists findings to look for during the evaluation of hip pain. Inspection should include seated and standing posture, transfers, and gait. Examination of leg length discrepancy and pelvic, femoral, tibial, and foot rotation should be assessed both in weight-bearing and noneweight-bearing positions, which enables the examiner to determine whether abnormalities are structural or due to abnormal movement patterns. Trendelenburg gait suggests subtle hip abductor weakness or pain with weight bearing. Patients with SCFE can be noted to have a waddling gait with an externally rotated foot, whereas a shortened externally rotated leg can also be indicative of a hip dislocation. Swelling, bruising, a palpable muscle defect, or pain with direct palpation of a structure can provide revealing clues to injuries such as muscle strains, muscle tears, or fractures. Severe and progressive thigh swelling and pain associated with a change in skin turgor should prompt suspicion of compartment syndrome and must be evaluated immediately for potential surgical decompression. ROM examination of both hips and the lumbar spine (and whether ROM provokes pain) should be evaluated. Athletes with reduced hip ROM may compensate by recruiting more lumbopelvic ROM and vice versa. Unfortunately, accepted “normal” hip ROM values based on age, gender, position, and active versus passive ROM are not well agreed upon in the literature. In general, patients with FAI often have reduced passive hip flexion and internal rotation [3], whereas patients with hip OA may progressively lose ROM in all planes. DDH often presents with excessive ROM in hip flexion and internal and external rotation. In addition to testing for bony limitations to ROM, the clinician should also evaluate for muscle contractures that may be contributing to or

Table 2 Physical examination tests to evaluate hip pain Nonspecific observations consistent with a hip disorder Antalgic gait Trendelenburg gait Lateral lurch gait Decreased or asymmetric stride length Foot internal or external rotation during stance and/or gait Asymmetry of iliac crest and greater trochanteric heights when standing and/or supine Tests suggestive of an intra-articular hip disorder Asymmetry or decreased passive hip range of motion Provocative hip tests Hip log roll test Anterior hip impingement test Internal rotation over pressure test Hip scour test Flexion, abduction, external rotation/Patrick test Stinchfield resisted hip flexion test Posterior hip impingement test Tests suggestive of extra-articular hip disease Palpation for pain Iliopsoas Abdominal muscle insertion Conjoint tendon Inguinal ring/posterior inguinal canal Pubic tubercle Adductor origin Greater trochanteric region Hamstring origin Muscle length tests Ober test Thomas test Muscle strength tests Trendelenburg sign Tests suggestive of a co-existing disorder or disorder outside the hip Reproduction of pain with active range of motion of the lumbar spine Neurologic deficits Sensory changes or asymmetry Deep tendon reflex changes or asymmetry Positive neural tension signs Slump-sit test Straight leg raise test Femoral nerve stretch test Obturator nerve stretch test Adapted from Prather [69].

supportive of abnormal movement patterns causing pain. For example, a short hip flexor and ITB in combination with muscle imbalances between hip abductors and external rotations can lead to groin and lateral hip pain. Audible or palpable snapping during movement should also be appreciated and identified as originating from the anterior groin, lateral hip, or intraarticular space. The snap is often recreated when moving the hip from flexion, abduction, and external rotation into full hip extension, adduction, and internal rotation. Special provocative examination maneuvers can be extremely helpful in determining intra-articular versus extra-articular and hip versus lumbosacral disease (or a combination). Table 3 and Figures 1-3 provide descriptions and images of provocative hip tests. Reproduction of

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Table 3 Provocative hip physical examination maneuvers Test

Purpose

Description of Test

Log roll test

Assess for intra-articular hip disease

Anterior hip impingement test

Assess for intra-articular hip disease, especially impingement and/or an anterosuperior labral tear Assess for intra-articular hip disease

The patient lies supine with hips and knees extended; examiner passively internally and externally rotates the test leg while stabilizing the knee and ankle so that motion occurs at the hip; a positive test reproduces anterior or lateral hip pain The patient lies supine; the examiner passively flexes the hip and knee and internally rotates and adducts the hip; a positive test reproduces anterior or lateral hip pain

Internal rotation over pressure test Hip scour test

Flexion, abduction, external rotation/Patrick test Stinchfield resisted hip flexion test Thomas test

Assess for intra-articular hip disease

Assess for hip disease and/or SI joint and low back disease

Assess for intra-articular hip or hip flexor disease Assess for hip flexor contracture

Ober test

Assess for ITB tightness

Posterior hip impingement test

Assess for intra-articular hip disease, especially a posterior labral tear Assess for hip abductor weakness

Trendelenburg sign

Whitman sign

Assess for SCFE

The patient lies supine; the examiner passively flexes the hip and knee to 90
, internally rotates the hip to end range of motion, and then applies a posterior force; a positive test reproduces anterior or lateral hip pain The patient lies supine; the examiner passively moves test hip into flexion and adduction end range; a downward force is applied along the axis of the femur while passively moving the femur in a circular fashion; a positive test reproduces groin, lateral hip, or posterior pelvic pain The patient lies supine; the examiner rests the ankle of the test leg on the opposite knee in a “figure 4” position; the opposite ASIS is stabilized with one hand, and the other hand applies pressure to the test leg’s knee downward toward the table; a positive test for hip disease reproduces anterior or lateral hip pain; a positive test for SI joint or low back disease reproduces posterior pelvic pain The patient lies supine; the test leg knee is extended, and the patient actively flexes the hip to 30
against resistance; a positive test reproduces anterior or lateral hip pain The patient sits at the edge of the table; the patient flexes the nontest knee to the chest and rolls onto the back while allowing the test leg to remain extended at the hip and hanging off the edge of the table; lack of full hip extension indicates hip flexion contracture; abduction of the leg indicates ITB tightness The patient lies on his or her side, with the test leg up; the lower leg is flexed at the hip and knee; the examiner passively extends the patient’s upper leg hip with the knee flexed at 90
; while supporting the knee, the examiner slowly lowers the leg; if the ITB is shortened, the leg remains abducted and does not fall to the table The patient lies prone with the hip and knee extended; the examiner passively extends, adducts, and externally rotates the hip; a positive test reproduces anterior hip or posterior pelvic pain The patient is standing; the examiner places his or her hands on top of bilateral iliac crests while the patient stands on the test leg in a single leg stance; the test is positive if the pelvis droops on the nonstance side, indicating hip abductor weakness on the side of the stance leg The patient is supine; hip flexion past 90
causes the hip to externally rotate

SI ¼ sacroiliac; ASIS ¼ anterior superior iliac spine; ITB ¼ iliotibial band; SCFE ¼ slipped capital femoral epiphysis. Adapted from Prather [69].

the patient’s pain in the groin or lateral hip with internal rotation over pressure and flexion/abduction/ external rotation have been shown to be the most sensitive of the hip-specific tests for detecting intra-articular disease (0.91 and 0.82, respectively) and also to have the highest positive predictive values (0.47 and 0.46, respectively). The Stinchfield resisted hip flexion test is most specific, but even so it only has a specificity of 0.32 [51]. Lumbosacral examination should include neural tension tests such a straight leg raise, seated slump test, and femoral nerve stretch test to assess for nerve root compression. Athletes with primary intra-articular hip disorders that cause pain with hip rotation may develop compensatory changes in lumbopelvic motion in an attempt to maintain the same net body rotation for sports such as tennis and golf. A secondary increase in lumbopelvic rotation can result in lumbar pain and degenerative changes. Lumbar rotation can be assessed

by having the patient lie prone while the clinician passively rotates the hip internally and externally while the knee is flexed to 90
. Lumbopelvic motion that occurs early during the arc of hip rotation signifies compensatory lumbopelvic rotation [52]. Narrowing the differential diagnosis for posterior pelvic pain using physical examination is challenging. Several provocative examination maneuvers designed to assess for SI joint disease exist, but each maneuver used in isolation has poor sensitivity and specificity. To be confident that a patient’s posterior pelvic pain is originating from the SI joint, multiple positive provocative examination maneuvers, in addition to a pain-relieving response to an image-guided diagnostic injection, should be present [53]. A description of the SI joint provocative maneuvers, which include distraction, compression, the flexion/abduction/external rotation (FABER)/Patrick test, the Gaenslen test, and sacral thrust, is beyond the scope of this article.

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Figure 3. Resisted active straight leg test.

Figure 1. Anterior hip impingement test.

Diagnostic Imaging Despite a thorough history and physical examination, imaging may be required to confirm a patient’s diagnosis. In this section we will focus on key concepts and limitations of various imaging techniques that are used to assess an athlete with hip pain.

Figure 2. Flexion abduction external rotation (FABER) test.

Plain Radiographs In addition to assessing for fracture, degenerative changes, intra-articular loose bodies, and inflammatory arthropathy, radiographs are also the best imaging modality for detecting subtle abnormal bone disease of the hip. To accurately diagnose structural abnormalities from radiographs, the images must be of acceptable quality. Clohisy and colleagues have described proper standardized patient and camera positioning for various hip views, techniques to assess for adequate image quality, and how to calculate common anatomic measurements from hip radiographs [54]. Unfortunately, even with high-quality radiographs, measurements taken from standardized radiographs may not have consistent inter-rater reliability [55]. The most helpful views of the hip to evaluate the acetabular shape are the anteroposterior (AP) and false-profile views, whereas the proximal femur is best visualized with the 45
Dunn, cross-table lateral, and frog-leg lateral views [54]. These views can assist in assessing degenerative changes consistent with OA, in addition to detecting more subtle bony abnormalities indicative of prearthritic hip disorders such as cam and pincer-type FAI, DDH, and acetabular retroversion. Because the 45
Dunn view best visualizes the anterosuperior head-neck junction and this is the most common site for maximal cam-type FAI deformity, in young athletes the recommended radiographic series includes standing AP pelvis, false-profile, and 45
Dunn views. This series exposes the patient to the least amount of radiation while still enabling the clinician to make measurements to assess for FAI, DDH, and acetabular retroversion [25]. The most common hip measurements, their diagnostic utility, and how to measure them from radiographs are detailed in Table 4. Because some people without hip pain still have radiographs consistent with bony deformity, the accepted cutoff values for normal measurements on hip radiographs have been a subject of much debate. This dilemma is particularly prevalent for FAI because a universally accepted cutoff angle would assist in standardizing research studies and accelerate understanding of the condition. The value of

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60
listed in Table 4 was determined by consensus of an international panel of experts in 2013 [25,56]. With this cutoff value, radiographs will be consistent with FAI in 8%-13% of asymptomatic males and 2%-7% of asymptomatic females [54,57]. Magnetic Resonance Imaging Compared with plain radiographs, magnetic resonance imaging (MRI) is more useful in assessing soft tissue disease of the hip and pelvis such as athletic pubalgia and osteitis pubis, muscle strain, and ligamentum teres rupture. As an example, an AP protocol noncontrast MRI can detect rectus abdominis muscle injury with 68% sensitivity and 100% specificity and can confirm adductor tendon injury with 86% sensitivity and 89% specificity [58]. MRI can also detect bone integrity injuries such as stress fractures and avascular necrosis earlier than plain radiographs, and MRI is useful to rule out inflammatory arthropathies, infectious abscess, and neoplasm. In contrast to extra-articular disease, MRI is not optimal in assessing intra-articular soft tissue hip disease. MRI only detects acetabular labral tears with a sensitivity of 66% and specificity of 79% [59]. It is even more limited in detecting acetabular cartilage delamination lesions that can accompany labrochondral junction injuries, with a sensitivity potentially as low as 22% [60]. Magnetic resonance arthrography (MRA) is the most sensitive imaging modality available to detect hip labral and chondral abnormalities. In a study of 102 hips, MRA detected labral tears with 71% sensitivity, 44% specificity, 93% positive predictive value, 13% negative predictive value, and 69% accuracy. For articular cartilage disease, MRA had a sensitivity of 47%, specificity of 89%, positive predictive value of 84%, negative predictive value of 59%, and accuracy of 67% [61]. In summary, it is important for the clinician to recognize that even negative MRA findings do not definitively exclude a labral tear or other intra-articular source of hip disease and pain. Ultrasound Ultrasound can be a powerful tool to evaluate superficial structures in the area of the hip. It is less expensive and can be more easily accessible than other imaging modalities, and it does not expose the patient to radiation. However, image quality and interpretation are extremely operator dependent, and thus clinicians should become well trained if they plan to incorporate this imaging modality into their practices. When evaluating the hip, ultrasound is particularly helpful for viewing superficial tendons, muscles, and bursae, such as the adductor muscles and the greater trochanteric region. It is the only imaging modality that can dynamically correlate hip snapping appreciated on examination with direct visualization of musculotendinous disease. A major limitation of ultrasound is

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its limited ability to evaluate deeper structures, especially in patients with larger body habitus. With regard to identifying anterosuperior acetabular labral tears, a small study of 16 patients found that ultrasound had 82% sensitivity, 60% specificity, and 75% accuracy, which was less robust than MRA. This study was conducted in patients all undergoing hip arthroscopy [62]. Diagnostic Injections Image-guided diagnostic injection is a valuable tool to confirm that disease of a joint or soft tissue structure found on imaging is actually associated with the athlete’s pain. Additionally, because false-negative results do occur with MRA and ultrasound, a positive response to a diagnostic injection can help guide a clinician’s treatment plan in a patient with negative imaging findings despite a strong clinical picture for a certain type of hip disease. We recommend a low-volume injection (eg, 4 mL) of anesthetic (such as 1% lidocaine and 0.25% bupivacaine) to attempt to decrease or eliminate pain that may be provoked by hip distension associated with larger volumes of injectate. A decrease in pain of at least 50% is considered a positive response to an injection. For intra-articular diagnostic (anesthetic only) hip injections, a positive response is 90% accurate that intra-articular disease is present (as confirmed by arthroscopy) [63], and when degenerative changes are seen on imaging at both the hip and spine, intraarticular hip injections can help distinguish hip pain with a sensitivity of 100% and a specificity of 81% [64]. Immediately after an image-guided injection, relief in previously positive provocative hip physical examination tests can be helpful in narrowing the diagnosis to an intra-articular hip disorder. An MRA of the hip after a positive diagnostic hip injection helps confirm that structural changes noted on the MRA may be related to pain. Other potential locations to perform ultrasoundguided diagnostic injections in the evaluation of hip girdle pain include the iliopsoas tendon or bursa, the greater trochanteric region, and the deep hip lateral rotators such as the piriformis [65]. Fluoroscopically guided SI joint and lumbar nerve root and facet injections also play a role in identifying the source of pelvic and thigh pain. Treatments for Common Local Causes of Hip Girdle Pain For most symptomatic hip disorders in athletes, nonoperative management consists of pain reduction, patient education, activity modification, movement retraining, and progression to return to play with a maintenance program. More nuanced treatment details depend on the cause of hip pain, but general principles largely can be subdivided by intra-articular versus

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Diagnosis and Treatment of Hip Girdle Pain

Table 4 Radiographic measurements to evaluate for femoroacetabular impingement Measurement/Sign

Purpose

Radiograph View

Abnormal Values


Alpha angle

Detect cam-type deformity

AP pelvis, >60 lateral, or Dunn views or CT/MRI

HNO

Detect cam-type deformity

Lateral

HNO ratio

Detect Lateral cam-type deformity Acetabular inclination Detect AP pelvis (To pincer-type ¨nnis angle) deformity or acetabular dysplasia

8 mm

<0.17 <0
or >10


Description of Measurement First, determine best-fit circle to the femoral head; the first arm of the angle is drawn from the center of the femoral neck to the center of the femoral head, and the second arm is drawn from the center of the femoral head to the point where the femoral head-neck junction first extends beyond the margin of the circle First, determine the axis of the femoral neck; then 2 lines are drawn parallel to the femoral neck axis: one at the anterolateral edge of the femoral head, and one at the anterolateral aspect of the femoral neck; the distance between these 2 lines is the femoral HNO The HNO distance is divided by the diameter of the femoral head

Lateral center-edge angle (of Wiberg)

AP pelvis Detect pincer-type deformity or acetabular dysplasia

<25
or 40


Anterior center-edge angle

Detect acetabular dysplasia Detect acetabular retroversion Detect acetabular retroversion Detect acetabular retroversion

False-profile pelvis

<20


AP pelvis

Presence of sign

The first arm of the angle is a line parallel to the transverse axis of the pelvis and crosses through the inferomedial aspect of the acetabular sourcil (the sclerotic weight-bearing zone of the acetabulum); the second arm connects the medial and lateral aspects of the acetabular sourcil; too small an angle suggests a pincer-type deformity, and too large an angle suggests dysplasia The first arm of the angle is a line perpendicular to the transverse axis of the pelvis and crosses through the center of the femoral head; the second arm connects the center of the femoral head with the most superolateral point of the acetabular sourcil; too large an angle suggests a pincer-type deformity, and too small an angle suggests dysplasia The first arm of the angle is a vertical line drawn through the center of the femoral head; the second arm connects the center of the femoral head with the most anterior point of the acetabular sourcil The sign is present when the anterior wall projects lateral to the posterior wall before converging at the lateral acetabular sourcil

AP pelvis

Presence of sign

The sign is present when the center of the femoral head is located lateral to the posterior wall

AP pelvis

Presence of sign

The sign is present when any portion of the ischial spine projects within the pelvic brim

Crossover sign

Posterior wall sign

Ischial spine sign

AP ¼ anteroposterior; CT ¼ computed tomography; MRI ¼ magnetic resonance imaging; HNO ¼ head-neck offset. Adapted from Prather [69].

extra-articular causes. In this section we will focus on management principles and controversies regarding treatment of some of the most common hip girdle conditions seen in athletes.

Prearthritic Intra-Articular Hip Disorders To minimize the risk of progression to activitylimiting, irreversible hip OA, prearthritic hip conditions such as FAI, DDH, and acetabular labral tears with and without hip deformity must be treated appropriately and in a timely manner. Given the “push through pain” attitude of many athletes, counseling regarding the potential consequences of disregarding medical advice is particularly important in this patient population. These athletes need to understand sport-specific movements that can exacerbate their pain and cause further joint damage, and their technique should be

critically evaluated and modified to preserve their joint health and quality of life through sports participation. Management of FAI and DDH with and without acetabular labral tears first warrants a trial of conservative care. Appropriate conservative care for these disorders has not been determined, and to date only 2 studies have prospectively described specific conservative care and outcomes [66,67]. A standardized nonoperative treatment protocol for these athletes has not yet been definitively determined, but descriptive reviews [68-70] and case reports [71,72] support the observation that in some cases, even athletes with labral tears can improve symptomatically and return to a satisfactory level of competition without surgery. A systematic review of outcomes for nonoperative management of FAI found that 3 of 5 studies showed favorable results. Activity modification and physical therapy were recommended 81% and 48% of the time, respectively [73]. Hunt and colleagues [67] monitored adults

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with clinically suspected prearthritic intra-articular hip disease. When treated with patient education, activity modification, a standardized physical therapy protocol, and intra-articular hip injection as indicated for pain control, at 1 year after presentation, patients (including those with labral tears with and without hip deformity) who continued with conservative management had no difference in pain or function compared with patients who chose to pursue surgery after the trial of conservative management. Additionally, subjects’ baseline pain, function, and degree of deformity did not affect their outcomes at 1 year, and the only statistically significant difference between patients who chose conservative treatment alone versus a trial of conservative management followed by surgery was that the latter group was more active at baseline [67]. There is no universally accepted physical therapy protocol for the treatment of prearthritic intra articular hip disorders [73], but in our opinion, therapy should focus on neuromuscular retraining and avoidance of movements that will cause further damage to the hip joint. The therapy prescription should include instructions to improve precision of hip motion to decrease anterior glide of the femur in relation to the acetabulum; optimize muscle strength and length of the hip flexors, extensors, lateral rotators, and abdominals; prevent hip hyperextension, rotation of the acetabulum on the femur when under load, and painful hip ROM; and educate athletes on necessary sports-specific and dayto-day activity modification (ie, avoidance of pivoting on the affected hip or sitting with the legs crossed) [67]. These recommendations are based on the work of Lewis and Sahrmann [74], who described therapy for patients with hip pain related to acetabular labral tears. For patients with significant persistent pain, intraarticular corticosteroid injections can play a role in the conservative approach to pain reduction. However, repeated steroid injections should be avoided in young athletes to minimize potential chondrocyte damage [75]. In patients who fail to experience an adequate improvement in pain and functional status with conservative measures, joint preservation surgery (both arthroscopic and open) may be a beneficial option, depending on the athlete’s specific osteochondral deformity. Substantial advancement in hip arthroscopic technique has occurred during the past several decades, and it is becoming clear that proper patient selection is imperative to achieve satisfactory surgical outcomes [76]. For instance, athletes requiring operative correction of mixed-type FAI deformity necessitate a more extensive hip preservation surgery than can be performed arthroscopically [76], and athletes with advanced articular degeneration usually have suboptimal responses to preservation surgery [77,78]. In patients who are not good surgical candidates, conservative management should focus on maximization of function and activity modification, rather than

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necessarily returning to baseline. Also of note, in persons who choose to proceed to surgery for FAI, on average female patients require a longer recovery period [79] and, similar to preoperative findings, report lower quality of life measures postoperatively than do male patients [80]. Hip Osteoarthritis Conservative management of hip OA includes relative rest and avoidance of pivoting, internal rotation, and end range hip flexion, in addition to therapeutic exercise for the pelvic girdle that addresses movement impairments, muscle inhibition, shortened muscles, and muscle strength deficits within a pain-free range of motion. Specified courses of nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen can be recommended to manage pain if this approach is safe from a medical perspective. Glucosamine supplementation can be considered, but studies have shown some to no improvement in pain and functioning [81]. Intra-articular image-guided corticosteroid hip injections have been found to transiently decrease symptoms from OA. Care should be taken to avoid repetitive injections because they contribute to cartilage destruction. Viscosupplementation has not consistently been proven to be beneficial and remains controversial. Further, viscosupplementation is not approved by the Food and Drug Administration for injection in the hip in the United States [82]. When conservative measures fail, surgical management can be considered. In young, active males, hip resurfacing can produce favorable results, but often surgery for hip OA involves total hip arthroplasty [17]. Of note, because females tend to present with more severe hip OA, they still report lower quality of life measures postoperatively compared with males [83,84]. However, females do experience a greater improvement in quality of life from total hip arthroplasty [85]. Conservative treatment of adhesive capsulitis is identical to the treatment of hip OA. If conservative treatment fails, examination of the hip with the patient in a state of general anesthesia is performed and arthroscopic versus open capsular release can be performed [41]. Extra-Articular Hip Girdle Conditions Greater Trochanteric Pain Syndrome GTPS is due to a combination of shortened, inhibited, or weak hip abductor musculature, frequently in combination with a tight ITB and tensor fascia lata. Rehabilitation should therefore focus on stretching the tensor fascia lata and ITB and strengthening the hip abductor, external rotator, and extensor musculature [86]. This rehabilitation should be performed in combination with activity modification and use of NSAIDS and physical modalities (eg, ice and heat).

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Corticosteroid injections can be considered in persons who have not responded to noninterventional measures or if the athlete is having difficulty sleeping as a result of the pain. This form of treatment is successful in more than 90% of cases [87]. However, recurrence is common. To reduce the likelihood of recurrence, one should carefully evaluate for biomechanical and kinetic chain abnormalities (eg, Trendelenburg gait and tight hip flexors) and correct those that are identified. If the aforementioned measures are not successful, extracorporeal shock wave treatment or a surgical bursectomy could be considered [88]. Snapping Hip Syndrome Initial management of external snapping hip is the same as that for GTPS, as previously described. Reduction in pain associated with the snap should be the primary goal. Internal snapping hip is also initially managed with activity modification, reduction of activities that activate or stretch the tendon complex, and use of NSAIDs or acetaminophen to assist with pain control. For internal snapping hip, therapeutic exercise should focus on optimizing the strength and length of the iliopsoas muscle tendon complex and motor control of the hip musculature, including hip extensors, abductors, and adductors [17]. If the athlete fails to improve after 3 months, a corticosteroid injection can be considered either between the ITB and the greater trochanter or to the iliopsoas bursa [89]. However, caution should be exercised because tendon rupture can occur after steroid injections. Ultrasound guidance aids in minimizing tendon rupture by allowing visualization and avoidance of the muscle-tendon junction and tendon insertion point. Relatively few patients require surgical tendon lengthening or release for snapping hip, but those who respond well to an image-guided diagnostic injection will likely have good response to surgical release [89]. Conclusion Hip and pelvic girdle injuries are common in athletes, and proper diagnosis of the cause can be challenging. The differential diagnosis should include intra-articular, extra-articular, and referred sources, in addition to the possibility of multiple coexisting conditions contributing to one another. A comprehensive history and physical examination are necessary to direct proper imaging and arrive at the correct diagnosis. With the exception of fractures and dislocations, essentially all hip disorders warrant an initial trial of conservative management, including athlete education, a therapeutic exercise program, and sports-specific activity modification. The athlete should then be reassessed for adequate improvement because without proper treatment, many causes of hip pain and dysfunction can result in chronic disorders and tissue degeneration. Symptomatic prearthritic intra-articular hip disorders are particularly

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Disclosure H.P. Section of Physical Medicine and Rehabilitation, Department of Orthopaedic Surgery, Washington University School of Medicine, 660 S. Euclid Ave, Campus Box 8233, St Louis, MO 63110. Address correspondence to: H.P.; e-mail: [email protected] Disclosures outside this publication: board membership, North American Spine Society (money to institution); honorarium, PM&R Journal Senior Editor (money to institution)

A.C. Department of Physical Medicine and Rehabilitation, Feinberg School of Medicine, Northwestern University, Chicago, IL Disclosure: nothing to disclose Submitted for publication August 12, 2015; accepted December 18, 2015.