Physical Therapy Management of Athletic Injuries of the Hip

Physical Therapy Management of Athletic Injuries of the Hip Jeff G. Konin, PhD, ATC, PT, and Charles C. Nofsinger, MD Growth in the overall number of individuals participating in organized sports has contributed to an increase in the prevalence of hip-related injuries. Rehabilitation goals established for an athlete require the inclusion of knowledge associated with both the physical and psychological demands of one’s sport and expectation. Developing an intervention that meets the needs of an athlete must include consideration of the most efficient method of returning one to athletic activity with minimal risk of compromising the healing process. While the majority of the athletic injuries to the hip involve damage to soft tissue components in the form of muscle strains, contusions, and capsuloligamentous insult, the nature of some weight-bearing and contact activities lend themselves to more traumatic injuries, such as fractures to the femur and pelvis. Likewise, similar stress-related fractures may be found as the result of repetitive stress to a weaker aspect of an osseous structure. The key to successful treatment intervention begins with understanding the process of formulating appropriate measurements and assessment tools to create a differential diagnosis of the injury to the hip. In some cases, formal rehabilitation, conservative or aggressive, may successfully manage the injury at hand; while, in others, a failed rehabilitative approach will require surgical intervention followed by additional therapy. Externally applied wraps and pads can be used as part of the treatment intervention of hip injuries for added protection when appropriate. Overall, an accurate assessment of a hip injury combined with an evidence-based approach can lead to successful rehabilitative outcomes. Oper Tech Sports Med 15:204-216 © 2007 Elsevier Inc. All rights reserved. KEYWORDS hip, athlete, rehabilitation, strain, fracture

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ith the growing number of individuals of all ages participating in athletic events, injuries to the hip are commonly seen. The age of an individual and the nature of the activity often play a role in the type of hip injury seen. In general, younger individuals present with musculoskeletal injuries, especially those related to immature development of structural components.1 High school athletes have been shown to have a relatively fair amount of hip injuries. Table 1 lists the percentage of hip injuries compared with overall injuries for high school sports. In 2001, the National Collegiate Athletic Association’s Injury Surveillance System highlighted the hip as being one of the most commonly injured anatomical areas for

Department of Orthopaedics & Sports Medicine, College of Medicine, University of South Florida, Tampa, FL. Sports Medicine & Athletic Related Trauma (SMART) Institute, University of South Florida, Tampa, FL. Address reprint requests to Jeff G. Konin, PhD, ATC, PT, Sports Medicine & Athletic Related Trauma Department of Orthopaedics & Sports Medicine, University of South Florida, MDC 106, Suite 511, 3500 East Fletcher, Tampa, FL 33613. E-mail: [email protected]

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1060-1872/07/$-see front matter © 2007 Elsevier Inc. All rights reserved. doi:10.1053/j.otsm.2007.11.001

sports, including baseball, men’s and women’s lacrosse, fall football, women’s volleyball, men’s and women’s soccer, field hockey, and women’s basketball.2 In this same study, it should be noted that such injuries readily occur in both practice and games settings. Collegiate athletes have a slightly lower percentage injury to the hip compared with high school athletes.2,3 Athletes and nonathletes often present with similar symptoms. Therefore, the management of such injuries may not differ between an athlete and a nonathlete. However, the goals of the individual and the physiological status of the tissue that has been impaired in addition to the underlying physical health status of the individual all contribute to the rehabilitative decision-making process. The goals of an athlete may be more physically demanding and require a facilitated temporal approach toward meeting these goals. As such, developing an intervention that meets the needs of the athlete must consider the most efficient method of returning one to athletic activity with minimal risk of compromising the healing process. The very foundation of this approach is not much different, if at all, when compared with the intervention of any nonathletic individual who encounters a hip

Physical therapy management of athletic injuries of the hip Table 1 Percentage of Hip Injuries Compared With Overall Injuries for High School Athletes Sport

% Hip Injuries

Baseball Softball Basketball (men) Basketball (women) Football Volleyball Soccer (men) Soccer (women)

16.8 17.0 14.7 16.6 17.3 16.2 29.1 26.9

Adapted from the National Athletic Trainers’ Association Injury Surveillance Study.2

205 soas muscle, active hip flexion and passive hip extension rely on these muscles for support and function. Strains to this area are common, frequent, and more likely to be found in those athletes who have decreased hip flexibility and or muscle strength. Such strains have been reported in swimmers resulting in the reduction and/or modification of one or more week’s training time.5 Loosli and Quick note that the breaststroke is most commonly related to hip injuries and they suggest an aggressive stretching and strengthening program that focuses on the hip flexors, adductor and abductor muscle groups, in addition to nonsteroidal antiinflammatories with the main goal of preventing a recurrent injury.5 Oftentimes after a strain to the rectus femoris or iliopsoas muscles, deficits in measurable active and passive hip exten-

injury. However, it is essential to recognize the urgency of the nature of return to activity for an athlete, the psychological components associated with injury to one who cannot compete, and the levels to which one can be pushed to reach optimal performance. Furthermore, athletically involved individuals may tend to be in better general physiological health than others; thus, tissue healing may occur at more rapid rates. It is also important to recognize that the function of muscles surrounding the hip will contribute to the overall production of force generated by upper limb dominated sports such as baseball and tennis.1 As a result, it is not uncommon to come across a swimmer or throwing athlete who complains of shoulder pain whereby the true underlying pathology may be related to a decrease in either hip joint range of motion of hip musculature strength.

Soft-Tissue Injuries of the Hip A majority of the athletic injuries to the hip involve damage to soft-tissue components. Although typically not as severe as bony-related injuries, the amount of actual tissue damage and the necessary intervention can range from minimal to extensive in nature. Structures such as muscles, bursa, and ligaments are included in this discussion. Muscles are often involved in rapid high-velocity contractions, oftentimes eccentric in nature, whereby the strain placed on a single muscle is greater than the stress that it can withstand.4 Muscles may also be damaged as the result of a direct blow, as seen in contact sports such as football, resulting in localized contusions and developing hematomas. A thorough evaluation and examination coupled with objective, measurable, and temporal goals will oftentimes lead to a successful outcome with soft tissue injuries to the hip.

Injury to the Muscles of the Hip Anterior Muscles At the hip, the quadriceps muscle group primary relies on the rectus femoris as the sole hip flexor of the group. However, as a result of a common distal insertion and neural innervation, injury to any of the other three quadriceps muscles must be recognized as having a resultant effect at the hip joint in addition to the knee joint. Working together with the iliop-

Figure 1 Thigh wrap for compression after a quadriceps muscle strain. (Color version of figure is available online.)

206 sion, and active hip flexion may result. This can be treated with soft-tissue mobilization, static stretching, friction massage, or proprioceptive neuromuscular facilitation techniques. The extent of the injury and the tolerance of the athlete will determine the type and progressiveness of the intervention. Regardless of technique chosen, the clinician should pay careful attention to isolating the muscle structure involved and avoid rotational compensation around the hip joint. Much of the treatment should focus on the reduction of pain, a common finding after acute muscle strains. Early care may also involve the use of externally applied wraps to assist with structural compression and provide proprioceptive feedback (Fig. 1) Forms of cryotherapy are helpful for superficial pain reduction but may not have any effects on the healing of the involved tissue nor the reduction of inflammation at the depths involved with muscle strains to this area. Electrical stimulation may be used to inhibit pain and prevent muscle atrophy in the early phases of rehabilitation, typically relying on sensory mode application with a comfortable waveform. Grade III muscle tears that result in palpable and observable defects may take significantly longer to heal (Fig. 2). Clark and coworkers advocate sagittal plane hold-relax exercises for the anterior thigh muscles to achieve optimal results not only for hip extension range of motion but to improve passive straight leg raise movements (Fig. 3).6 Using this technique and establishing flexibility gains in both directions within the sagittal plane can reduce intervention time

Figure 2 A grade III quadriceps muscle tear with a visible defect.

J.G. Konin and C.C. Nofsinger

Figure 3 Sagittal plane hold-relax exercises for the anterior thigh muscles used to increase passive hip extension range of motion and passive straight leg raise movements.

and contribute to the prevention of injuries related to both the hip flexors and extensors. Contusions to the anterior thigh area are commonly seen in sports such as football, soccer, and rugby. In football, thigh pads are required to reduce the severity of such injuries (Fig. 4) However, in other sports that require physical contact, oftentimes no pads of this kind are worn. Significant contact to the anterior thigh area will result in acute bleeding and hematoma formation that may also lead to decreased hip range of motion. If not addressed early, strength deficits could result and performance would be affected. It has been reported participation may be limited anywhere from a few days to a few weeks after contusions to this area.7,8 During early intervention, the physician must carefully screen for the possibility of myositis ossificans formation, usually found in the mid-belly of the rectus femoris muscle. This heterotrophic bone formation will rapidly generate into larger proportions with aggressive stretching during the acute phase to subacute phases of healing.9 Should the athlete develop myositis ossificans, aggressive intervention such as passive stretching should only be performed in later stages of healing, and one should expect him or her to have increased levels of discomfort, both with the treatment and general movement into knee flexion or hip extension positions. A combination of these 2 positions, knee flexion and hip extension, will be most uncomfortable. Mysositis ossificans has been treated

Physical therapy management of athletic injuries of the hip

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Figure 5 Thomas Test used to assess iliopsoas and rectus femoris tightness.

Figure 4 Thigh pads are required to reduce the severity of quadriceps contusion injuries.

successfully using a combination of iontophoresis with a 2% acetic acid solution followed by 8 minutes of pulses ultrasound at 1.5 w/cm2.10 Wieder suggests performing this treatment 3 times a week for 3 weeks, reporting a 98.9% decrease in the size of an ossified mass and a full return of range of motion.10 Unsuccessful treatment of myositis ossificans may require surgical intervention.11 Iliopsoas Syndrome The iliosoas bursa lies just anterior to the pelvic brim and hip capsule and may be irritated by acute trauma or overuse.12 Iliospoas syndrome, as it is referred to, will present with anterior hip pain found to increase with the level of activity, localized palpable tenderness in the femoral triangle region, and a self-described feeling of the hip “snapping,” and a positive Thomas test (Fig. 5)9,12-15 The audible and perceptual “snap” may be the result of a sudden movement of the iliopsoas tendon as it travels over either the bony prominence of the anterior inferior iliac spine, the iliopectineal eminence, or the ridge of the lesser trochanter.15,16 However, a similar snapping also can be the result of fibrosis to the gluteus medius muscle.13 On occasion, pain may also be referred to the L4 to L5 dermatome.17 Johnston and coworkers12 have reported accompanied muscle weakness with hip internal and external rotation when testing with the hip flexed to 90° (Fig. 6).12 It is also not as common to have any symptoms of pain reproducible with passive mobilization, something not

seen with other bursal tissue that has become impinged or inflamed.18 Conservative treatment interventions are oftentimes successful and may take up to 8 weeks for resolution.14 Such treatment consists of general stretching of the iliopsoas, global hip muscle strengthening, electrical stimulation for pain, and thermal agents for muscle relaxation.9,18,19 The importance of emphasizing stretching and strengthening of surrounding hip muscles have been found to be essential in the treatment of ballet dancers.20,21 Sammarco has described the movements related to hip rotation required for proper dance technique and has noted that on femoral bone ossification at approximately age 11, certain movements will only be accomplished and maintained via soft tissue stretching around the hip joint.22,23 On the basis of similar beliefs, Johnston and colleagues propose a rotational strengthening program to treat iliopsoas syndrome.19 The authors found a 77% successful outcome when targeting the internal and external rotaters of the hip through the use of elastic resistance in an

Figure 6 Athletes with iliospoas syndrome will exhibit hip internal rotation muscle weakness with the hip flexed in a position of 90°.

208 isotonic manner. Aspinall suggests a thorough evaluation of the spine and pelvis, in addition to the hip, since the iliopsoas muscle attaches to these structures and may be the contributing factor to excessive muscle tightness or stretch.24 Physical therapy interventions may also be supplemented with local corticosteroid injections in the serous bursa and oral antiinflammatory medications.12,18,25 When conservative intervention fails, surgical options that divide the psoas aponeurotic fascia, lengthen the iliopsoas tendon, or resect the prominent bony spur contributing to the snap may be indicated.18,25,26

Posterior Muscles On the posterior aspect of the thigh, the 3 hamstring muscles play a large role in producing hip extension force as well as for allowing hip flexion rang of motion. A strain to the hamstring muscle occurs in a similar sudden burst of movement as with the quadriceps muscle group. When this occurs, the athlete will complain of a feeling of a “pull” and may oftentimes note that he or she heard an audible “pop.” Examination will reveal painful and weak active knee flexion and hip extension, passive hip flexion with simultaneous knee flexion, and a palpable defect in the area of the ischial tuberosity may be found.11,27 This type of an injury is commonly seen and will effect those athletes more severely who require eccentric maneuvers on the part of this muscle group during activity. The location of the strain itself to the hamstring musculature may be different according to the nature of the activity. DeSmet and Best note that the biceps femoris is the most commonly injured hamstring muscle, closely followed by the semitendonosus.28 Hamstring injuries often involve one muscle, but the same authors report a 33% occurrence of multiple hamstring muscle injuries, with 40% of these occurring distally.28 Askling reported on two case studies, both involving hamstring strains, whereby the eteiology and injury sites were different.29 In one case, a sprinter running at maximal speed encountered a strain to the distal semitendinosus muscle. In the other case, a dancer performing a slow stretch encountered a strain in the proximal semimembranosus tendon. It remains to be seen if there is a strong correlation between the type of activity and the localization of the strain itself, though it is possible that such a relationship exists. The treatment intervention, like the mechanism of injury, is similar to that of the quadriceps group. However, more work has been done in the area of hamstring muscle strains that supports a relationship between causation, prevention, and injury. Hamstring muscle weakness, decreased hamstring muscle flexibility, lack of proper warm-up, fatigue, an improper flexor/extensor ratio of strength, increasing age, menstrual disturbances, and previous posterior thigh injuries are suggested as predisposing factors to hamstring injuries.30-38 With respect to hamstring muscle strength, the eccentric phase of the contraction appears to play a significant role in performance status. In athletes who take part in sprint-like activities, poor eccentric hamstring strength has

J.G. Konin and C.C. Nofsinger been demonstrated to have a relationship with predisposing one to injury.39,40 Specifically, lower eccentric peak torque measurements have been recorded in those sprinters who have previously injured hamstring muscles versus those with no hamstring injury.39 This suggests an emphasis be placed on eccentric strengthening during the rehabilitation program. Furthermore, studies have shown that when strength training isokinetically or isotonically, individuals will make marked gains in both concentric and eccentric force production.33,41,42 Brockett and coworkers suggest eccentric exercise training of the hamstring muscles allows for an increase in series compliance within some muscle fibers, serving as a protective strategy against injury via adaptation.43 Performing these exercises in a closed kinetic chain and typical weightbearing forces will optimize the specificity of the training regime. Petterson and coworkers encourages endurance training to supplement eccentric strength training as such exercise has been shown to be associated with site-specific increases in bone mass.44 Mobilization of the hip and knee joint after a hamstring strain should begun as soon as tolerable to facilitate a proper alignment of the regenerating muscle fibers, limit the extent of connective tissue fibrosis, and promote recapillarization of the damaged area.34,45 Some have supported the use of neural mobilization techniques as an intervention to reduce any posterior thigh pain attributed to adverse neural tension.46-48 One of the keys to assessing improvement associated with hamstring muscle injuries is to establish a formal measurement technique. Various methods exist to measure the flexibility of the hip joint and length of the hamstring muscle group.49,50 Hui and Yuen advocate a modified back-saver as the most reliable and practical method for assessing hamstring and low back flexibility.50 Although decreased hamstring flexibility has been noted as a predisposing factor to potential hamstring strains, it is unclear as to whether or not a stretching program for these muscles truly enhances one’s overall hip flexibility. Hartig and Henderson reported a decrease in the number of lower-extremity injuries to lower infantry basic trainees after the implementation of hamstring flexibility program during the course of a 13-week basic training.51 Bandy and coworkers suggest a 30-second duration daily static stretch is most effective in increasing range of motion, with no significant gains being made with a longer duration stretch or an increased frequency of stretching.52,53 By contrast, Halbertsma and colleagues studied the effects of one session of static stretching to the hamstring muscles and concluded that any increases in extensibility found are not related to the single stretch, but rather associated with an increase in stretch tolerance over time.54 James and coworkers examined the effects of the Feldenkrais technique and found it to be an ineffective method for altering hamstring length through awareness of movement.55 Recent work compliments our knowledge of stretching as it relates to hamstring flexibility. Funk and coworkers demonstrated significant gains in hamstring flexibility when moist heat application of 20 minutes was compared with 30 seconds of a static stretch.56 Feldman and coworkers have explored hamstring flexibility and adolescent growth using

Physical therapy management of athletic injuries of the hip the popliteal angle as a measurement and found no relationship between developmental growth and a decrease in flexibility during the peripubescent period.57 These results suggest that growth plays a very minor role in flexibility changes. By contrast, with individuals aged 65 and older, Feland and coworkers purport longer static stretch hold times for the hamstring muscle group to achieve both greater immediate and more sustained gains in range of motion.58 Although they were unable to detect a difference in gains between static stretch and proprioceptive neuromuscular facilitation techniques, Worrell and coworkers did conclude that increasing one’s overall hamstring flexibility will increase one’s hamstring muscle performance when tested at slower isokinetic speeds.59 Perhaps of most interest is the work of Sullivan and colleagues, who demonstrated that successfully placing the pelvis in an anterior pelvic tilt60 position is more important than the particular individual stretching method chosen.61 From a more practical perspective, Wenos and Konin suggest a warm-up activity equivalent to 70% of one’s heart rate reserve or a respiratory exchange ratio of 1.0 is superior to the effects of static stretch or proprioceptive neuromuscular facilitation for hip range of motion and hamstring flexibility.62,63 The authors equate these physiological levels to approximately a 4-minute endurance-type warm-up. Rarely are hamstring muscle strains treated surgically. In addition to a focus on eccentric strength training, conservative intervention may also include thermal agents, gentle passive stretching, and externally applied wraps. When the palpable and reported pain appear to be near the proximal attachment of these structures along the ischial tuberosity, imaging studies should be used to rule out avulsion fractures before any progressive passive hamstring intervention.64 Intramuscular corticosteroid injections have been noted to hasten the return to play and amount of game and practice time missed for professional football players, though this is not commonly agreed on by all practitioners as a treatment of choice.65

Medial Muscles Groin strains, muscular strains to the adductor group, are commonly seen in athletes who partake in sports that require lateral movement, such as basketball, tennis, volleyball, and skiing, to name a few. Loosli and Quick define hip/adductor/ flexor strains in swimmers and identify the adductor magnus and brevis as being the muscles most often involved with adductor strains.5 They suggest a stretching protocol that begins with 10-second holds and progresses to static holds of 1 minute in length before activity. The authors also describe an assessment tool for adductor flexibility: The athlete assumes the “butterfly” groin stretch position with the heels 6 inches from the crotch. The athlete should be able to bring his or her knees down to within 6 inches of the floor, measured from the lateral side of the patella.5 Although in theory a similar modalities approach would be taken to the conservative treatment approach to adductors muscle strains as is provided to quadriceps and hamstring muscles, in practicality such is not the case. This is not seen as

209 a result of any evidence based protocol, but rather merely on the simple fact that some athletes are not comfortable having cryotherapy or ultrasound treatments applied to the groin area, as the majority of adductor strains occur at the proximal musculotendinous region. Gentle and progressive stretching to this area, however, should be maintained and encouraged if not for the sole purpose of improving one’s flexibility to the adductors muscles for prevention of injury recurrence. Although not reliably supported, the use of external wraps to limit the amount of active and passive hip abduction has been used in the athletic population and appears to provide a sense of proprioception and comfort to athletes (Fig. 7). The question of exactly how effective such a technique may be remains to be answered.

Lateral Muscles The muscles on the lateral aspect of the hip include the gluteus medius and the tensor fascia latae. These muscles are rarely strained as a result of athletic activities. Rather, the repetitive contraction of these muscles, coupled with the compression that they produce as they track over the greater trochanteric region contributes to other soft tissue pathology. Like the anterior aspect of the hip, muscles on the lateral aspect may compress over the prominent bony ridge of the greater trochanter, compressing the bursa that lies between. This process may lead to trochanteric bursitis or a snapping hip phenomenon. Snapping of the hip is a direct result of the proximal aspect of the iliotibial bands as it is formed off of the tensor fascia latae rubbing on the greater trochanter during movement of the hip.11,66 This overuse type injury may also present with symptomatic pain along the lateral aspect of the knee where the iliotibial band lies over the lateral femoral condyle, crossing this structure from anterior to posterior during flexion and extension movements of the knee.67 The key with symptoms of pain and snapping that present either at the lateral aspect of the hip or the knee is to recognize the nature of the tissue structure. As the tensor fascia latae travels distally to become the iliotibial band, the physiological make-up is one that is less conducive to elastic and ultimately plastic deformation as a result of gentle, prolonged stretching at its distal attachment. Thus, localized intervention to control pain and inflammation may be necessary at both the hip and the knee, but stretching techniques should focus on the proximal structures that possess greater musculotendinous properties. As a result of the biomechanical alignment of the knee joint, stretching the iliotibial band at this location would essentially require an adduction moment, something that the tibiofemoral joint does not lend itself to easily. Beyond progressive stretching approaches to elongate the lateral structures, the clinician may choose to use phonophoresis or iontophoresis for the application of topical medications. It is unclear whether or not such treatments truly penetrate to the desired level of tissue depth at the hip, and the size of the athlete must also be considered when opting for such treatment intervention. External compression wraps are not advised with snapping hip symptoms because they

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Figure 7 External wrap used to assist with compression and limiting range of motion for hip adductor strains.

may facilitate greater compressive forces over the greater trochanter. Treatment may also include corticosteroid injections and nonsteroidal antiinflammatory drugs.35,68,69 Pettitt and Dolski have proposed a corrective neuromuscular approach to the treatment of this type of a friction syndrome.70 Their approach was based on a single case study focusing on an alternative to orthotic intervention, and consisted of diagonal proprioceptive neuromuscular facilitation patterns using a repeated-contraction sequence in addition to generalized stretching and strengthening of surrounding musculature during a 10-week period of reduced training.70 Surgical intervention, although rare, has been reported. Zoltan and coworkers excised an ellipsoid-shaped portion of the iliotibial band overlying the greater trochanter and removed the trochanteric bursa for seven patients who complained of a painful and snapping hip.9 With an average follow-up length of 55 months, the authors reported that four patients had significant improvements, with a fifth patient not responding well, only to undergo a repeat procedure and become asymptomatic 1 year later. The greater trochanteric bursa lies between the tendon of the gluteus medius and the anterior–superior portion of the greater trochanter, and also serves to separate the greater trochanter from the gluteus maximus muscle. It too can be irritated through repetitive compression, most often the result of a tight proximal iliotibial band. Compression also may occur from leg length discrepancies and a weakened gluteus

J.G. Konin and C.C. Nofsinger medius muscle on the ipsilateral side.9 Trochanteric bursitis is commonly diagnosed in all age groups, although it is not as prevalent with younger athletes and its pathologic nature tends to peak between the fourth and sixth decade of life.71 With younger athletes who complain of symptoms associated with active hip abduction and passive hip adduction following a forceful movement that served as the etiology of the pain, one should suspect a possible muscle tear or avulsion fracture to the iliac crest region.11,27 Rarely seen in adolescents, symptomatic complaints mimicking trochanteric bursitis should raise the suspicion of an apophyseal injury to the iliac crest or or avulsion to the lesser trochanter.72,73 In the young athlete, apophyseal injuries may be the result of skeletal immaturity, repetitive microtrauma or muscle-tendon imbalance.72 Pain in this region may also be the result of a direct blow to the iliac crest region, slightly more proximal from the greater trochanter. This type of an injury, referred to as a “hip pointer,” may be very painful to touch and present with increased pain on active hip abduction and passive hip adduction. Contusions to the iliac crest may need a few weeks for the pain to subside completely, and may be treated with local cryotherapy and a protective pad to reduce the amount of force received by the involved area should an athlete decide to return to competition (Fig. 8). Local anesthetic injection is a safe and effective treatment of hip pointers. Treatment for trochanteric bursitisis is identical to that of other bursal related inflammatory conditions, requiring a re-

Figure 8 A contoured pad designed to reduce the amount of force from a blow to the iliac crest following a hip pointer injury.

Physical therapy management of athletic injuries of the hip Table 2 Acceptable Interventions for the Treatment of Trochanteric Bursitis (ICD-9-CM Code 727.3) as Outlined in the Guide to Physical Therapy Practice60 Manual therapy techniques Massage Mobilization/manipulation Passive range of motion Prescription, application and, as appropriate, fabrication of devices and equipment Adaptive devices Assistive devices Orthotic devices Protective devices Supportive devices Electrotherapeutic modalities Electrotherapeutic delivery of medications Electrical stimulation Physical agents and mechanical modalities Athermal agents Cryotherapy Hydrotherapy Light agents Sound agents Thermotherapy Compression therapies Mechanical motion devices

duction of activity and a symptomatic focus on controlling localized pain and inflammation. Preventing a recurrence of trochanteric bursitis requires a thorough evaluation to determine the cause of the overuse and compression in the region. Myofascial trigger point techniques may be helpful as well as general progressive stretching to the hip abductor muscles as tolerated. Glucocorticoid and lidocaine injections have been prescribed, demonstrating long-term relief.74,75 Oftentimes, a complete gait assessment must be performed as the condition may arise form faulty alignment or training errors.9 The Guide to Physical Therapy Practice outlines acceptable interventions for the treatment of trochanteric bursitis (ICD9-CM Code 727.3) (Table 2). Perhaps of greatest concern when providing physical therapy interventions to one whom is believed to have greater trochanteric bursitis is to completely rule out all other pathologies that could cause lateral hip pain. Collee and coworkers reported that in 45% of hospital-referred patients with chronic low back pain, symptoms of greater trochanteric bursitis were present.75 In these patients, radiating pain and paresthesia in the leg was also found to be present in addition to lateral hip pain. These findings were more consistent in females who had a longer duration of underlying low back pain. Collee and coworkers in another study looked prospectively at 100 patients diagnosed with low back pain and found 35% to have symptoms of trochanteric bursitis and 43% to possess symptoms of iliolumbar syndrome.76 Traycoff supports the challenge of a differential diagnosis with lateral hip pain as he has labeled pain to the lateral hip associated with such conditions as lumbar radiculopathy and lumbar facet syndrome as “pseudotrochanteric bursitis.”77

211 Perhaps of greater concern are reported cases of a nondisplaced complete femoral neck stress fracture found in a 46year-old male runner78 and a giant cell carcinoma reported in a young athletic woman nine months after being diagnosed and treated for trochanteric bursitis,79 both presenting with similar lateral hip pain increasing with activity. With true trochanteric bursitis that does not respond to conservative physical therapy care, a surgical resection of the bursa may be indicated.11,27 Whether conservative or surgical treatment is implemented for lateral hip pain, inflammation and a decreased ability to function, the strength of the hip abductor muscles should always be considered as an underlying source of the problem as well as a mechanism for prevention of future lateral hip injuries. Goldberg and coworkers have identified approximately a 5% weakness in the hip abductor and flexor muscles during the screening of preparticipation sports examinations.80 Furthermore, Fredericson and coworkers have shown weaker hip abduction strength in the iliotibial band syndrome affected leg compared with the unaffected leg.81 Dickenson and coworkers identified a 50% deficit in hip abduction torque nearly 2 years after the incidence of acetabular fractures.82 As a result of such overall findings and clinical experience, Sahrmann advocates the relationship between muscle imbalances and pathology as one of the primary contributors to dysfunction.83 Nadler and colleagues have also found a relationship between weak hip abductor strength in collegiate-aged females and a higher incidence of low back pain.84 Athletes who do not regularly stretch their hip external rotators may develop piriformis syndrome. This condition may also develop as a result of blunt trauma to the buttock region.9 Piriformis syndrome presents posterior thigh pain and posterior leg radiculopathy as a result of the sciatic nerve being compressed as it lies beneath the piriformis muscle.11 Pain also may be present with sitting, as the muscle will be both on stretch and exposed to external compressive forces. Both active external rotation and passive internal rotation will be diminished and painful. The combined movement of hip flexion, adduction and internal rotation has been reported as a method of assessment.85 Palpable tenderness may be noted, indicating the specific location where tissue tightness may exist. Treatment for piriformis syndrome focuses on stretching of the external rotator muscle itself. Deep manual therapy and low frequency ultrasound may also assist in elongating the piriformis muscle tissue. Nonsteroidal oral anti-inflammatory medications and corticosteroid injections have been used, depending on the severity of the patient’s pain.86,87 When treating an athlete for piriformis syndrome, accurate measurements should be recorded to assess progress and minimize recurrence of injury. Simoneau and coworkers have demonstrated varying hip internal and external measurements between seated and prone positions, recommending strongly the importance of documenting measurement position and reproducing assessment methods in the same position.88

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Capsuloligamentous Injuries The hip joint relies heavily on the large surrounding musculature and the strength of the components of the joint capsule. Capsular and ligamentous injuries to the hip are not as commonly seen as musculotendinous injuries to the same region are, yet they are prevalent enough to warrant discussion. Furthermore, oftentimes injuries to these static structures may result in significant disability and impairment for an extended period of time. Cardiovascular conditioning should be considered when performing long-term physical therapy for all athletes who may not be able to return to full participation as the result of a serious hip injury.

Osteitis Pubis The central inferior aspect where the 2 innominate bones meet is connected by the pubic symphysis. On occasion, this fibrocartilaginous structure may become inflamed. This more often presents itself in athletes who participate in sports such as running, soccer, hockey, tennis and any competition that encompasses an endurance type event.11,89 An athlete who has osteitis pubis will complain of minimally provoked discomfort in the groin region, exacerbated by passive stretch or active contraction of the hip adductor muscles. An accompanying “pop” may be elicited on movement of this area, and pain may appear to radiate to the anterior aspect of the proximal thigh. Treatment for this condition is oftentimes conservative and may include a reduction or modification of activity with simultaneous intake of nonsteroidal antiinflammatory medications. The cause of osteitis pubis may not be a result of any type of overuse injury or violent stretch. Instead, an underlying infection to the pubic region may preexist, warranting a full medical evaluation and potentially prophylactic antibiotics.90 Table 2 outlines the factors that may modify the frequency of visits necessary to successfully treat osteitis pubis, as described in the Guide to Physical Therapy Practice, 2nd edition.60

Dislocation of the Hip A significant amount of force is required to dislocate one’s hip joint. However, such a force may occur in athletic events such as football, rugby, and soccer.46,76,91 Acutely, management of a hip dislocation involves a clear recognition of the signs and symptoms. Most hips that are dislocated do so in the posterior direction, with the athlete presenting with an adducted and internally rotated femur. Athletes have commonly reported a very loud audible “pop” on impact.92-94 Weightbearing activity is intolerable, and the athlete should be stabilized and evaluated by a physician if a dislocation is suspected. With hip subluxations, weight-bearing activity may be possible, and a careful evaluation should rule out additional pathology to include as fractures. If the suspected subluxation or dislocation occurs in a posterior direction, integrity of the sciatic nerve must be assessed both immediately and subsequently during early rehabilitative phases. Medical imaging tests are performed to assess for the positioning of the femoral head as well as any associated fractures.

J.G. Konin and C.C. Nofsinger A reduction of the dislocation may need to be performed under anesthesia and could require an open technique should associated fractures be present that necessitate a fixation. For this reason, no attempts to reduce a hip dislocation should be made when providing early intervention in an acute situation of care. The initial physical therapy for a traumatic hip dislocation includes restricted and protected range of motion for the hip, nonweight-bearing activity for approximately 4 weeks, and well leg exercises. Serial radiographs are taken to assess the status of the joint. Submaximal isometric exercises can be initiated early on, progressing to pain-free isotonic exercises that do not apply undo stress to the hip joint. Partial weightbearing activity to the involved limb can begin during the fifth week after injury, with strengthening exercises and range of motion gradually progressing. Young athletes who encounter a dislocated hip and complete a thorough rehabilitation program often have positive outcomes and return to competitive athletics. However, neurovascular complications, such as a nerve palsy or osteonecrosis, have been reported and should be screened after a hip dislocation.9

Bony Injuries of the Hip Because of the nature of collision and endurance related sports, fractures to the femur and pelvis have been witnessed and may occur as the result of direct trauma or via repetitive stress to the weaker aspect of the osseous structures. Most commonly found are fractures to the acetabulum, the femoral head, femoral neck, and femoral shaft. Although vastly different in their anatomic location, signs and symptoms for each are somewhat similar, and the treatment intervention for each is initially limited to conservative rest and palliative care. Physical therapy must be tailored to the individual injury. Stress fractures develop as a result of the weakening and subsequent failure of a bone. In the hip, individuals who progressively increase the duration of repetitive impact loading to the lower limb are most susceptible.9 Oftentimes, stress fractures are difficult to diagnose as an athlete will complain of pain deep in the joint area that may mimic other pathologies such as trochanteric bursitis and general groin pain that can be referred from many locations, including the low back.64,78 Korpelainen and coworkers have identified individuals with high longitudinal arches, leg length inequalities, excessive forefoot varus, and menstrual irregularities as being in the high-risk category for developing a stress fracture.95 Recurrent stress fractures have been identified in runners with high weekly mileage training regimens.95 Parker described a femoral neck stress fracture to a 21-year-old male collegiate basketball player who had a nontraumatic onset of diffuse anterior hip pain.96 In this case, hip flexion range of motion was limited and painful, hip flexors appeared restricted and painful, and the athlete exhibited positive Thomas, straight leg raise, and FABER tests. With this case, nonweight-bearing ambulation was followed for the first 6 weeks after an open reduction internal fixation of the femoral neck. Full return to activity did not occur until 18 weeks

Physical therapy management of athletic injuries of the hip postoperatively. Stress fractures to the femoral shaft also have been reported.97,98 Surgical intervention may not be necessary because of the surrounding osseus structures being able to withstand dispersed forces. However, physical therapy intervention should include a gradual and tolerable return to full weight bearing accompanied by progressive resistive exercises.97,98 The underlying physiologic nature of the healing tissue and the age of the athlete must all be considered and will play a crucial role in the length of time for return to full weight-bearing activity. Durney, in an unusual situation, reported a case of 2 midshaft femur fractures in 2 different individuals during a single football game.99 Both athletes identified a clear and distinct “pop,” and each were ultimately treated with an intramedullary rod. With a mid-shaft femur fracture, care should be taken during postoperative physical therapy intervention to minimize lower extremity edema and hematomas from forming. Weight-bearing activity can progress from partial to full from weeks 2 through 6, and gentle range of motion to both the hip and knee joints should begin immediately after surgery to reduce adaptive shortening of the quadriceps and hamstring muscle groups. Osteochondral lesions of the femoral head have been reported in young, high-level athletes and may present as persistent hip or groin pain. Weaver recommends magnetic resonance imaging to detect these focal lesions as early as possible so that appropriate treatment may be implemented to prevent late degenerative sequelae.100 Fractures to the femoral neck, lesser trochanter, and intertrochanteric region are not as common as those to the femoral head, shaft or greater trochanter, although they have been reported in the literature. Quarrier and Wightman have described a challenging differential diagnosis in a ballet dancer who presented with a 6-year history of chronic hip pain and dysfunction.101 During the course of this individual’s physical therapy intervention, outcomes were unsuccessful and the initial physical therapy assessments did not support the physician’s working diagnoses, including over the course of time snapping hip syndrome, iliopsoas tendinitis, and trochanteric bursitis among others. As such, follow-up imaging tests were performed that revealed a lesser trochanteric bony ossicle that ultimately required surgical removal. Once removed, the dancer was pain-free within 3 weeks, was not referred for formal physical therapy, but did follow an exercise routine including basic lower extremity range of motion and strengthening exercises. One year after the surgical excision of the ossicle to the lesser trochanter of the hip, this individual remained pain-free and was able to return to full activity and dance.101 Campbell has described intertrochanteric and subtrochanteric fractures as a result of trauma oftentimes seen with alpine and cross-country skiers.27 Referred to as “skier’s hip,” these fractures seem to be associated with both the high speed of the activity and the potential contact forces placed on these smaller areas of the femur. Fractures of this nature require a standard open reduction and internal fixation and require lengthy rehabilitation periods of progressive range of motion and strengthening exercises. In the case of a skier, participation following a surgically repaired trochanteric fracture may take up to a year before returning to full partic-

213 ipation.27 With respect to a recreational athlete, femoral neck and pertrochanteric fractures have been reported in individuals greater than 35 years of age who participate in the activity of in-line skating.91 In fact, it appears as though the greatest risk imposed with in-line skating is the prevalence of a severe injury in the form of a fracture, increasing proportionally as the participant ages. As with all other activities and sports, the experience and physical conditioning will serve to contribute to the risk of injury. In all athletic participants regardless of age, there appears to be a higher than normal incidence of fractures to the acetabulum as compared with other regions of the hip.1,102-107 Stilger and coworkers described a traumatic acetabular fracture occurring to an intercollegiate football player whereby the mechanism of injury was a flexed and internally rotated hip with a fully extended knee, while distal compressive forces were applied to the foot from the playing surface.107 This mechanism of injury for a posterior hip dislocation is a classic one but will oftentimes present with no obvious deformity or increased accessory motion on examination.103,105,106 Athletes who suffer acetabular fractures may be able to bear weight with accompanied diffuse pain. Frank suggests that the appearance of a leg length discrepancy not previously found on an individual accompanied by a shortened and internally rotated limb on the affected side should raise suspicion for an acetabular fracture.105 Others have reported a large scrotal hematoma following an acute acetabular fracture, known as a “Destot sign,” raising the importance of a full physical therapy diagnosis following trauma to the hip.103 Other general screenings to rule out fractures to the acetabulum should include a thorough neurological assessment, localized palpation, and applied pressure to the iliac crest in a posterior direction to create a compressive force on the acetabulum.103,107 Treatment of acetabular fractures will depend on the stability of the bone itself. Stable fractures may respond well to conservative physical therapy after 6 to 8 weeks nonweight-bearing activity. Unstable fractures will require surgical intervention to fixate the structure, allowing for a greater likelihood of healing to occur.103,105-107 Physical therapy intervention after an acetabular fracture is no different than that of other regional fractures to the hip in terms of a general and progressive approach to improving one’s range of motion, strength, balance, and proprioception. The most important consideration appears to be having an accurate differential that does not omit a fracture to this area that may potentially lead to poor physical therapy outcomes and further medical complications to the individual. One should not always assume that a forceful contact need occur to acquire an acetabular fracture. Delude in 2002 reported on an otherwise-healthy 19-year-old female collegiate basketball player who complained of a “sharp and stabbing” pain to the posteriolateral aspect of her hip after a sudden change of directional movement.104 With this mechanism of injury, it would appear that the athlete could have easily sustained a muscle strain to one of the surrounding hip dynamic structures. However, x-rays, magnetic resonance imaging and cat scans all revealed with certainty a 1-inch by 1/2-inch poste-

J.G. Konin and C.C. Nofsinger

214 rior acetabular rim fracture that required an open reduction and internal fixation.104

Unexplained Hip Pain Physical therapy diagnosis related to athletic injuries of the hip can be challenging. Such complaints posed by athletes related to hip pain and dysfunction can be related to a sudden unexpected movement, a direct traumatic blow, or in some cases no known etiology whatsoever. The key to successful treatment intervention begins with understanding the process of formulating appropriate measurements and assessment tools to create a differential diagnosis of the injury to the hip. The practicing physical therapist must recognize the relationship between improper postural alignment and hip pathology.83 Knowing that low back originating dysfunction often mimics hip pathology such as greater trochanteric bursitis is key to not mistreating an individual for what is believed to be a hip injury.75-77 Lumbar radiculopathies and facet disorders can exacerbate one’s physical condition both acutely and over an extended period of time, if left untreated.77 Conditions such as ankylosing spondylitis in adolescents and juveniles can often be misdiagnosed as the physical therapist may too easily equate a traumatic incident to the etiology of reported hip pain and thus intervene with less than optimal approaches of care.108 Although difficulty may persist when making an initial physical therapy diagnosis for what appears to be hip related pathology, prolonged, unsuccessful treatment intervention warrants further evaluation, referral and questioning to rule out additional or other pathologies that may have gone undetected.22 Mansour and Steingard suggest refractory pain without signs of improvement after initial and conservative physical therapy for 4 weeks indicate laboratory work and ancillary radiologic tests to rule out more serious and undetected underlying medical conditions.109 Other clinicians have advocated the use of earlier radiographic studies in an attempt to identify true pathology as soon as possible so that appropriate intervention may begin.40,64,110 To the physical therapist who may be the very first health care provider to assess an athlete with a complaint of hip pain, a standard algorithm of examination and evaluation must be implemented.

Protective Devices for the Hip Region As previously mentioned, various externally applied wrappings and pads can be used as part of the treatment intervention of hip injuries. Any wrap or pad applied externally should be done with a clear understanding of the purpose of the intervention. The physical therapist should not only be familiar with the pathology, pathomechanics, and anatomical components being addressed, but also possess the knowledge of material diversification, procedural steps involved with taping techniques, and an awareness of the legal aspects of external devices as they apply to the rules of the individual athlete’s sport.62,111

In general, there are 5 main purposes of protecting the hip area with externally applied devices: (1) dispose and absorb forces, (2) support structures by limiting anatomical movement, (3) enhance proprioceptive feedback to the limb, (4) support musculotendinous structures via compression, and (5) secure protective pads.62,111 When used appropriately, each of these purposes of externally applied devices to the hip will serve to prevent further insult to injury. The majority of supplies used to protect hip injuries are soft in nature, though occasionally a pad of some type could be developed from a more solid thermoplastic type material. Athletic associations typically have governing bodies that will establish guidelines for the allowable use of protective equipment and adding. These rules have are put into effect not only to protect the injured athlete, but also to look out for the well-being of those athletes who may come into physical contact with the injured athlete wearing protective equipment or padding. Thus, the safety of all must be considered when applying an external device. Knowing the rules of each sport as they pertain to protective equipment will behoove a physical therapist whose goal is to return an athlete to sport as quickly and as safely as possible. Miller has proposed the following questions to be considered when returning an athlete to athletic participation with the intervention of protective materials and equipment112: 1. Does the equipment protect the area of concern appropriately? 2. Can the athlete perform the skills required for his or her sport and position while wearing the device? 3. Will the device maintain proper anatomic position? 4. Is the device potentially hazardous or injurious to other participants? 5. Is the device legal by the rules and regulations of the athlete’s particular sport?

Summary The rehabilitation of hip injuries continues to evolve in a progressive manner. Of greatest importance is an accurate diagnosis based on a thorough history, clinical examination, and warranted ancillary tests. Though the timing goals related to return to participation differ from an athlete versus a nonathlete, the baseline approach to both the evaluation and the rehabilitation guidelines should be similar in an effort to reduce impairments and facilitate functional performance.

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