Disorders of the contractile structures

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Disorders of the contractile structures



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Pain in the buttock usually results from a lesion of the lumbar spine, the hip joint or the sacroiliac joint. Muscular lesions are very uncommon. Even if resisted movements elicit pain in the buttock, gluteal bursitis is more likely to be the cause, especially if one or more passive movements also elicit the pain.


Pain in the groin more often results from a tendinous or muscular lesion. It is good to remember, however, that groin pain may also result from a lesion of the lumbar spine, the hip joint or, uncommonly, the sacroiliac joint. Also, a number of intra-abdominal pathological conditions, such as appendicitis, gynaecological disorders and inguinal or femoral hernia, may cause groin pain (see online chapter Groin pain).1



Resisted flexion


This test primarily examines the psoas muscle. However, a strain or weakness may be obscured because of active contraction of other synergistic muscles such as the rectus femoris, sartorius, tensor fasciae latae and some of the adductors.



Pain


If resisted flexion is strongly opposed and is painful, the following conditions should be considered:




Tendinitis of the psoas


Tendinitis of the psoas is rare. It may result from an acute hyperextension of the hip or from an overuse injury.2–6 Iliopsoas impingement is also an uncommon cause of pain after total hip replacement.7 The lesion is always located in the femoral triangle and thus accessible to the palpating finger. It can be identified just below the inguinal ligament between the pulsating femoral artery medially and the sartorius muscle laterally.



Treatment

Deep transverse friction is very effective.8 Sonography-guided iliopsoas peritendinous injections with steroid have also been proposed as a safe and effective method of treatment.9



Deep friction

The patient sits upright on the couch with the hip joint in 90° of flexion and the knees extended – with the hip extended in the supine position, it is not possible for the finger to penetrate deeply enough because of the taut overlying tissues. The therapist sits at the patient’s side facing the thigh, with the index and middle fingers placed at the painful tendon in the femoral triangle, just lateral to the femoral artery and medial to the sartorius muscle. The thumb is placed at the outer part of the hip and used as a fulcrum (Fig. 48.1). The transverse movement of friction is imparted by alternating flexion and extension of the wrist and elbow, together with some adduction–abduction movement at the shoulder. In acute cases, treatment can be started the day after onset. However, really deep friction should not last more than 1 minute and is repeated daily, with a gradual increase in the treatment time. In the second week, treatment is performed on alternate days. It is then carried out deeply throughout and for about 15 minutes. A good result is to be expected in 2 weeks. Chronic strain requires 15 minutes of friction, two or three times weekly, depending on the result of each session. A lesion that has persisted for years will respond to 6–8 sessions of deep transverse friction. Treatment is very painful but, in our opinion, there is no alternative. Finding the exact point is not easy and requires a good understanding of local topographical anatomy.






Obturator hernia


This lesion is principally found in thin, elderly women, often with a history of recent weight loss, obstipation or chronic respiratory disease. The patient complains of numbness or pins and needles, which may eventually culminate in intense pain at the anterior and medial side of the thigh down to the knee. These symptoms result from compression of the obturator nerve at the obturator foramen by a prolapsed fold of peritoneum. Absence of the adductor reflex test is a sign of involvement of motor conduction of the same nerve.11 Pain on resisted hip flexion is explained by pressure exerted by the psoas on the hernia. The differential diagnosis can be made when resisted flexion becomes negative after the patient has been in the Trendelenburg position for upwards of 2 minutes; the effect of gravity is to reduce the prolapse, which is no longer painfully squeezed during active contraction of the psoas.



Pain and weakness


Pain and weakness on resisted flexion can be present in the following conditions.



Avulsion fracture of the anterior superior iliac spine


Avulsion fractures occur more commonly in skeletally immature athletes than in adults because young patients’ tendons are stronger than their cartilaginous growth centres. The same stress that causes a sartorius tendinitis in an adult can cause an avulsion fracture of the anterior superior iliac spine in an adolescent. The fracture does not become widely displaced because of the surrounding thick periosteum.


The lesion is well known in young sprinters, soccer players and jumpers.12 While running, the subject feels a sudden painful click in the groin and upper part of the thigh. From that moment further activity is impossible and the athlete leaves the track with a limp; even walking is painful.13,14 On examination, resisted flexion and resisted lateral rotation of the hip and resisted flexion of the knee are all painful. Palpation reveals ecchymosis and palpable tenderness at the anterior superior iliac spine where the sartorius muscle is attached. Radiography shows slight separation of the iliac spine. Spontaneous recovery is the rule and takes 2–3 weeks. During this period, however, total bed rest is not necessary. Movement should be permitted to the limits of pain but return to sports activity should be allowed only from the time that clinical examination becomes fully negative.



Avulsion fracture at the apophysis of the lesser trochanter


This may be seen in schoolboys and young athletes. There is no history of sudden onset because the lesion appears to be caused by overuse.15 The complaint is of groin pain during walking. Clinical examination shows a normal range of passive movement but resisted flexion is weak and provokes pain. This should be reason enough to obtain a radiograph, which shows separation at the lesser trochanter. In most instances 2 or 3 weeks’ bed rest in a half-sitting position will be enough for recovery to take place. Once the patient can walk without pain, standing is allowed.


It is important to remember that avulsion fractures of the lesser trochanter in adults are almost always the result of metastatic bone disease.16





Painless weakness






Resisted extension



Pain


Pain on resisted extension hardly ever has anything to do with the gluteus maximus, in which a lesion occurs only after a direct blow and recovers spontaneously within a few days. However, a contracting gluteus maximus may compress an inflamed gluteal bursa and thus indirectly provoke pain in an inert structure (transmitted stress). Pain after prolonged contraction of the gluteal muscles indicates a particular form of intermittent claudication.


If there is hamstring tendinitis or sprain of the sacrotuberous ligament, resisted flexion of the knee is then also painful (see ‘Resisted flexion of the knee’, p. 658).




Buttock claudication


Claudication is the symptomatic expression of peripheral artery disease in the leg. It is confined as pain (aching, heaviness, cramping or burning) that is produced with a similar level of walking, disappears after several minutes of standing and occurs at the same distance once walking has resumed.17 Classically, it appears in the calf and/or thigh, but sometimes is confined to the buttock region only and is then caused by a proximal arterial stenosis (bifurcation of the aorta, common iliac, internal iliac and gluteal arteries).18 The essential history is that of a buttock pain that forces the patient to stop walking, improves in a minute or two and reappears when the patient starts walking again. The routine clinical examination is completely negative. An additional test – active extension of the hip in prone-lying position – may reproduce the buttock pain (see p. 625). The usual reduction in femoral pulse may be absent if the stenosis is located on the hypogastric or gluteal artery and there is no substantial damage to the aorta–iliac axis.19 Arterial stenosis is confirmed by Doppler ultrasound or arteriography (Fig. 48.2).20





Resisted adduction



Pain



Adductor longus


Pain on resisted adduction that is localized to the groin usually points to the adductors. While the adductor longus, adductor magnus, adductor brevis and pectineal muscles are all adductors of the hip, of these the adductor longus is most often injured in sports.2,2124


The mechanism of an acute injury is usually that of a sharp cutting movement, which causes a forceful eccentric contraction of the muscle. Acute lesions are common in soccer players and often result from a sudden slip on a muddy field, which stretches or tears the muscle or tendon fibres.25 Alternatively, the lesion starts as an overuse phenomenon, such as repetitive abduction and adduction movements of the leg in the skating stride or in defence movements in basketball. It also occurs in high-jumping athletes and ballet dancers26 and has been described in middle-aged cricket bowlers and ice-hockey players.27,28 Lastly, it is a well-known lesion (‘rider’s sprain’) in horse sports.


Pain is provoked mainly on resisted adduction but full passive abduction may also hurt because it stretches the injured muscle fibres.29 Imaging procedures are usually unnecessary. However, ultrasound, although operator-dependent, can confirm the diagnosis.30


There are three possible locations of the lesion:



The exact site of the lesion is found on palpation and is more often musculotendinous, a few centimetres below the pubic bone, than tenoperiosteal. Exceptionally, the uppermost part of the muscle belly itself is at fault.



Differential diagnosis

Although pain in the groin during resisted adduction usually indicates a lesion of the adductor longus, this is not always so. Strong adduction indirectly pulls on bones and ligaments of the pelvic ring and, if a pathological condition is present in this region, the transmitted stress causes pain. A detailed discussion of pubic lesions can be found in the online chapter, Groin pain. The following three lesions are the most important.

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Jun 5, 2016 | Posted by in ORTHOPEDIC | Comments Off on Disorders of the contractile structures
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