CHAPTER 11
Hip Injuries
Michael M. Weinik, DO, Reed C. Williams, MD, and Ilya Igolnikov, MD
The number of athletic injuries to the hip and pelvis in sports is low in general, ranging from 5 percent in the running athlete to 18 percent in hockey players. Amenorrhoeic females may have a higher incidence of stress fractures, but males have higher percentages of injuries such as athletic pubalgia. As life expectancy increases for both sexes and the trend to remain physically active into later adulthood continues, it appears that every athlete will have a fair chance of suffering a sports-related injury to the hip or pelvis. Nearly every competitive sport requires a strong contribution from the pelvis and hip.
Managing hip and pelvis injuries can be difficult because the hip and pelvis coupling mechanism that transfers strength and power from the legs to the trunk (and vice versa) must also help absorb, dampen, and distribute the impact of running and jumping while providing the mobility to crawl, crouch, squat, bend, stand, and make every motion in between. Attached to the hips and pelvis are the largest and most powerful muscles in our bodies, which often act on the hip and pelvis with extremely long lever arms as created by the length of the legs and the height of the trunk. This fortunate anatomical arrangement allows the performance of amazing athletic feats but unfortunately places great physical demands on these structures, which sometimes leads to injury. In this chapter we discuss the more common injuries to the hip and pelvis in athletes and strategies to avoid and treat them.
Injury | Page |
Adductor Tendinopathy | |
Osteoarthritis | |
Greater Trochanteric Tendinopathy | |
Iliopsoas Tendinopathy | |
Adductor Strain | |
Hip Labral Tear | |
Adductor Canal Syndrome | |
Pelvic Stress Fracture | |
Pelvic Avulsion Fractures | |
Snapping Hip Syndrome | |
Hip Pointer | |
Osteitis Pubis and Athletic Pubalgia | |
Coccygeal Fracture | |
Sports Hernia | |
Sacroiliac Joint Injury | |
Pelvic Nerve Injury |
ADDUCTOR TENDINOPATHY
Common Causes
Tendinopathy of the lower limb is quite common in athletes because of the elevated level of strain exerted on the limb during many sports. Although traditionally categorized as a tendinitis, which implies an inflammation, many clinicians now regard these injuries as resulting from an ongoing degenerative process rather than ongoing tendinitis. Adductor tendinopathy (tendinosis) is usually a chronic injury associated with repetitive strain of the muscular origin of the hip adductors. Microtears at the muscular origin might also occur that are not large enough to cause bleeding and thus do not initiate healing, which chronically adds to the condition. Adductor tendinopathy typically begins as a mild injury that is not properly rehabilitated or responds poorly to rehabilitation, and as the athlete continues to compete, the once-mild injury leads to loss of function. After a certain point, even minimal stress on the tendon origin produces pain. In an effort to minimize pain, the athlete adjusts movements, which leads to localized weakness at the injury site, which in turn ultimately results in loss of endurance. Lower-limb tendinopathy tends to be sport specific, with most adductor injuries occurring in kicking athletes, hockey players, gymnasts, and horseback riders.
Identification
The diagnosis of adductor tendinopathy is made primarily by the athlete’s medical history and a physical examination in which tenderness is noted along the musculotendinous origin of the hip adductors, along the inferior edge of the pubic bone (in the upper thigh and groin). If the diagnosis is still in question, ultrasound or magnetic resonance imaging (MRI) might be useful in pinpointing the location and extent of injury.
Treatment
Traditional treatment for tendinosis includes physical therapy, analgesics, anti-inflammatory medications, and local injection of anesthetic and corticosteroid. If symptoms do not respond to this conservative approach after six months, surgery may be considered, which involves cutting through the principal tendon insertion and reattaching it into the pubis (bone). Physical therapy typically consists of therapeutic massage, stretching, transcutaneous electrical nerve stimulation (TENS), and active strengthening of the hip musculature. Unfortunately, active physical therapy has been shown to be very helpful for only about one-third of athletes. The effectiveness of anti-inflammatory medication has not yet been proven. The injection of local anesthetic and corticosteroid usually gives only short-term relief of symptoms. The use of percutaneous tenotomy with or without adjunct prolotherapy has garnered preliminary evidence supporting its efficacy. As if treatment results were not grim enough already, another study showed that only 63 percent of athletes returned to their previous level of ability after surgery.
Although traditional treatments for this injury have been lackluster, the future holds promise that biomechanical abnormalities will continue to be identified and emerging modalities will prove to be more effective.
Return to Action
Athletes may return to action once symptoms have subsided, which might take up to six months. The rate of failure to return to previous level of ability can be as high as 25 percent. No significant bracing or taping options have been shown to be effective.
OSTEOARTHRITIS
Common Causes
Osteoarthritis (OA), sometimes called degenerative joint disease, is estimated to affect 12 percent of 25- to 75-year-olds in the United States. Osteoarthritis of the hip is typically a noninflammatory disease process characterized by destruction of the proximal end of the femur (thigh) bone as it attaches to the hip socket (acetabular cup), along with deterioration of the hip socket in which the femur bone rests. The loss of the articular hyaline cartilage surface of the bone as it wears down causes a narrowing of the joint space, subchondral cyst formation, and the development of marginal bone growth, otherwise known as osteophytes or spurring. The exact cause of these pathologic changes is uncertain, but physiological and biomechanical factors such as age, obesity, genetics, joint alignment, joint laxity (possibly attributed to iliofemoral ligament and acetabular labrum degeneration or tears or both), and muscle weakness likely have a role in the disease process.
The condition is often aggravated by repetitive hip movements and strenuous prolonged physical activity involving standing, walking, running, climbing, and squatting heavy weights. Athletes who participate in sport activity that requires single-limb support or pivoting of the hip joint, such as tennis, other racket sports, or track and field events, may have a particularly high incidence of OA-related pain. Episodes of single-limb support during sports can cause forces up to 14 times the body weight to be transferred through the lower limb. In a person with slowly developing hip OA that is asymptomatic during everyday activities, symptoms might be elicited in situations in which the hip is put under unusual stresses.
Identification
The typical symptoms of pain and stiffness most often occur after a period of inactivity, although OA of the hip usually has an insidious onset of symptoms, with a gradual escalation of pain that might become truly noticeable only during sports. Pain can be felt in the groin, or laterally in the hip region, and might radiate down the thigh or even into the knee. Hip pain from OA is often relieved significantly with rest. Athletes with severe symptoms from OA might also report weakness of the hip muscles, in part due to pain inhibition.
Diagnosis is typically made by a standard hip X-ray, which is ordered if the physician suspects OA based on physical examination findings such as limited passive hip range of motion and pain with movement, particularly internal rotation. A hip MRI provides a more detailed assessment of articular surface (chondral cartilage and subchondral bone) injury and loss, inflammation, and degenerative changes to the supporting soft tissues (labrum, ligaments, tendons, joint capsule, and muscles).
Treatment
Treatment begins with a conservative regimen consisting of some or all of the following: lifestyle modifications, physical therapy, nutritional supplementation, pharmaceuticals, injections, and surgery. In patients who are overweight, weight reduction can be one of the most important factors in relieving symptoms; in some patients, losing weight is enough by itself to relieve hip pain.
Physical therapy and an exercise regimen consisting of restoration of range of motion, targeted strengthening of the core, hip girdle, and thigh musculature, and proprioception and coordination training as well as sport-specific tasks can be quite effective in reducing symptoms, although there is mixed literature based on the severity of the pathology. The use of cold and heat modalities is helpful in the acute and subacute phases. Soft tissue mobilization including myofascial release, active release therapy, and therapeutic massage is helpful for surrounding associated muscular pain.
Analgesic medications, predominantly nonsteroidal anti-inflammatory medications (NSAIDs), are the mainstay of treatment for OA. Acetaminophen also works well for athletes with mild to moderate symptoms and athletes for whom NSAIDs are contraindicated or poorly tolerated. In some instances, a period of non-weight bearing on crutches or a hip brace in slight flexion and abduction (or both of these) may provide temporary relief of pain.
If symptoms continue despite conservative treatment, intraarticular injection of a corticosteroid (glucocorticoids) with ultrasound or fluoroscopic guidance should be used sparingly because deleterious effects to the chondral surfaces have been recognized with frequently repeated injection. Intraarticular platelet-rich plasma (PRP) and stem cell therapy have gained attention and anecdotal support; however, firmly convincing research and generalized support are still lacking. Newer advances in arthroscopic hip surgery can address labral and extraarticular processes that can contribute to hip arthritis (i.e., joint laxity, labral tears or degeneration or both). Symptomatic moderate to severe hip arthritis with associated functional impairment that fails to show improvement with an extended course of nonsurgical management would warrant referral for surgical consultation for a potential total hip replacement.
Return to Action
After treatment with conservative measures as just described for four to six weeks, the athlete can slowly return to sport-specific rehabilitative therapy measures while being closely monitored for return of symptoms. If symptoms recur, the athlete should refrain from the inciting activity and return to additional conservative measures of relative rest, physical therapy, and medications. Additional advanced imaging such as MRI would be warranted at this time. The athlete must be relatively pain free, demonstrate full range of motion and full strength, and demonstrate the speed and agility demanded of the specific sport before returning to play.
GREATER TROCHANTERIC TENDINOPATHY
Common Causes
Trochanteric tendinopathy (often called greater trochanteric bursitis, tendinosis of the external rotator musculature of the hip, or more generally greater trochanteric pain syndrome) is relatively common, particularly in younger athletes. It includes inflammation of any or all the bursae in the region or chronic degenerative changes of the tendons with associated neovascularization without evidence of acute inflammation.
Tendinopathy of the lateral hip is often caused by changes in the attitude of the limb during activities such as adduction (movement of the lower limb toward the body) or internal rotation of the hip, which put the bursae under unusual stress, making them irritated and inflamed. Bursitis is commonly seen in long-distance runners. Tendinosis is often associated with other pathologies of the lower limb, such as osteoarthritis or rheumatoid arthritis, iliotibial band tightness, and leg-length discrepancy. Tightness of the iliotibial band (ITB) also causes an increase in the compressive forces on the bursae against the greater trochanter, increasing the likelihood of irritation.
Identification
The most common symptom of greater trochanteric tendinopathy is lateral thigh pain that radiates down to the lateral knee. Night pain is common, and individuals may not be able to lie on the affected side. Symptoms are exacerbated by activity such as walking, running, or climbing. This syndrome sometimes occurs acutely but most commonly progresses chronically.
No specific laboratory or imaging is needed to diagnose tendinopathy of the hip; typically, diagnosis is based on the athlete’s history and a thorough neurological and musculoskeletal examination. An exam begins with an attempt to elicit tenderness with palpation over the greater trochanter; however, tender points might be present anywhere along the lateral aspect of the thigh. Forced passive adduction or active abduction (movement of the lower limb away from the body) and external rotation of the hip against resistance might make symptoms worse. The presence of ITB tightness should be evaluated, and leg lengths should be precisely measured. Ultrasound or MRI can be useful to help clarify the diagnosis in difficult cases.
Treatment
Treatment options can be divided into musculoskeletal and pharmacological treatments. Musculoskeletal treatment includes relative rest, local heat, and therapeutic ultrasound for their analgesic properties and to facilitate stretching of the surrounding tissues; stretching exercises; correction of muscle strength imbalance; and correction of leg-length discrepancy (if present). Pharmacological treatment includes analgesic medications, anti-inflammatory medications, and corticosteroid injections. For long-term success, both musculoskeletal and pharmacological treatments are usually necessary. A plan that incorporates only pharmacological treatment ignores the structural pathology that caused the bursitis in the first place. That said, in some cases a correction of the musculoskeletal pathology is not possible, such as osteophytes (caused by OA) irritating the bursae.
In the case of a mild hip bursitis, anti-inflammatory medications and rest might be all that are needed. In moderate to severe cases of hip bursitis, oral medication usually is not potent enough to resolve the inflammatory process. For these athletes it is necessary to perform a trochanteric bursa injection, which deposits a combination local anesthetic and cortisone directly into the involved bursa. When performed by a physician who can accurately access the inflamed bursa, this procedure is usually very effective. In the case of tendinopathy, there is evidence for the efficacy of percutaneous needle tenotomy (with emerging literature to support the use of prolotherapy or other novel biologic agents).
Return to Action
The athlete may return to action once pain subsides, which typically occurs within a few weeks. Return should be slow and conservative. As is true of other hip injuries, there are no significant bracing or taping options.
ILIOPSOAS TENDINOPATHY
Common Causes
The iliopsoas muscle is the powerful thigh muscle that flexes the hip. It is one of the strongest muscles in the body. Iliopsoas tendinitis is an inflammation of the iliopsoas’ tendon. Often, the inflammation spreads to the bursa, which rests next to the tendon, producing iliopsoas bursitis. Iliopsoas tendinitis is most common in runners, soccer players, gymnasts, and dancers who tend to perform repetitive hip flexion movements. Tendinosis is suspected when no signs of inflammation are noted but imaging shows degenerative fraying of the tendon with signs of neovascularization on ultrasound.
Identification
The most common symptom is pain in the front of the thigh, sometimes radiating down the thigh. A snapping sound or sensation may be noted as the tendon moves across the pelvis during hip flexion. Symptoms are exacerbated by activities that require repetitive hip flexion, including running uphill and kicking.
No specific laboratory test or imaging study is needed to diagnosis iliopsoas tendinopathy, although ultrasound or MRI may be used to confirm the diagnosis. The diagnosis is typically made based on the athlete’s history and a thorough neurological and musculoskeletal examination. Point tenderness over the iliopsoas tendon, as well as pain with resisted hip flexion, is characteristic of the condition.
Treatment
Initial treatment includes anti-inflammatory medication and avoidance of the offending repetitive motions. Ice may provide some relief, although usually only for very thin athletes because this tendon lies quite deep within the upper thigh. Physical therapy that incorporates a structured stretching and strengthening program can be helpful. In difficult cases, an injection of steroid and anesthetic can be performed under ultrasound guidance or percutaneous needle tenotomy for more chronic tendinosis.
Return to Action
The athlete may return to action once pain subsides, which typically occurs within three to six weeks. Return to sport should be gradual. As with other hip injuries, no significant bracing or taping options are available.
ADDUCTOR STRAIN
Common Causes
The muscles of the medial thigh include the adductor muscle group and the gracilis. Adductor muscle strains are common in ice hockey and soccer but can be seen in all sports. Injury generally occurs following a sudden contraction of the adductor group with the thigh externally rotated and the hip abducted. Risk factors for adductor injuries include hip muscle weakness and imbalances (the adductors being weaker than the abductors), poor flexibility, and prior injury. These injuries are more likely to occur during the preseason and in athletes with less experience.
Identification
The athlete might experience the injury as a sudden painful event or as a progressive, insidious development of pain. Pain is noted in the medial thigh or groin and is worse with adduction (pulling the thigh toward the midline of the body) against resistance. Tenderness at the musculotendinous junction generally occurs. Complete rupture results in a palpable defect or mass distal to the pubis. Avulsion injuries might occur, as might avulsion fracture of the origin of the adductor group. This is similar to a hamstring avulsion but involves a different muscle group with a different attachment site. Athletic pubalgia (see p. 235), osteitis pubis (see p. 235), hernia (see p. 239), and hip joint OA (see p. 220) should all be ruled out as possible sources of the groin pain. X-rays can rule out avulsion fractures and osteitis pubis. Magnetic resonance imaging can evaluate the possibility of other conditions and localize and quantify the extent of muscle and other soft tissue injuries.
Treatment
Treatment for adductor strains is similar to that for other muscle strains. The treatment starts with PRICE (protection, rest, ice, compression, elevation) and the athlete using crutches if needed. Once pain subsides, the athlete can begin isometric exercises and then progress to isotonic exercises as tolerated. Ice and electrical stimulation are used throughout. Stretching is important and is done primarily to keep the muscle pliable and pain free, thus reducing risk of reinjury. Initiate jogging and sprinting as tolerated. If no pain occurs with straight running, begin pivoting and cutting activities. Surgical treatment (adductor tenotomy) may be considered if the athlete fails to improve after six months of physical therapy.
Return to Action
Athletes may return to play when flexibility and strength of the thighs are fairly symmetric, and when they can perform agility and sport-specific activities without difficulty. Return time can vary from one week for minor strains to six weeks or more for more severe strains.
HIP LABRAL TEAR
Common Causes
The hip labrum is a cartilaginous extension of the bony acetabulum, adding depth and stability to the hip joint. Both nociceptive (pain) and proprioception (position sense) free nerve endings exist in the labrum, accounting for the pain and perceived sense of hip instability when the labrum is injured. Labral tears often result from single traumatic events, such as a tackle in football or rugby, or a fall while skiing or cycling. They can also be caused by repetitive stress such as running or skating. Depending on the cause of injury, tears might develop along any area of the labrum.
Identification
Labral tears could cause pain in the lateral hip, anterior hip, medial groin, or even the buttocks, depending on the exact injury site. The anterolateral labrum is most commonly injured and should be suspected when the anterior labrum is stressed and produces either pain or a sense of instability during thrusting the hip forward, pivoting, or kicking. One should suspect posterior labral tears when similar symptoms are elicited by pushing posteriorly through a flexed femur as during thrusting the hip backward. Active range of motion of the hip might produce a snapping sensation, which could be a result of a tight ITB laterally or a hypermobile iliopsoas tendon anteromedially. Generally, if the hip is truly passively put through its range of motion (meaning the athletic trainer, physical therapist, or physician performs all the motion and the patient is at complete rest), these clicks are absent or less noticeable. However, should they persist or if range is restricted on passive motion, then an intraarticular injury such as a labral tear, chondral injury, or degenerative changes should be suspected.
Plain X-rays of the hip might prove helpful in identifying acetabular dysplasia, a condition in which the acetabulum, the cup-shaped portion of the hip joint, is irregular or abnormally shaped. Acetabular dysplasia allows abnormal and less constrained motion of the femoral head (the ball portion of the hip joint); this can stress the labrum and predispose an athlete to labral tears, osteitis pubis (see p. 235), or OA, which might mimic or accompany labral injuries. Magnetic resonance arthrogram (MRI enhanced by a diluted contrast solution injected into the hip beforehand) has been shown to improve sensitivity of detection of labral tears over conventional MRI. Many labral tears fail to be detected and are found only on arthroscopic evaluation of the hip joint.
Treatment
Initial conservative treatments are often helpful in alleviating pain. Athletes should avoid activities that stress the labrum (e.g., pivoting and twisting on the hip) and excessive loading of the hip (e.g., squats and hip extensions). If pain is not relieved or range of motion not restored with these initial measures, a hip joint cortisone shot and use of a cane or crutches may be considered. A comprehensive course of six to eight weeks of rehabilitative therapies can help correct strength imbalances and flexibility deficits about the hip girdle, improve balance and proprioception, and identify errors in sport-specific activities or training programs that might have contributed to the labral injury.
Should the conservative measures fail to bring relief, surgical labral repair or debridement (the surgical removal of damaged tissues) must be considered. Pain relief is not the only reason to consider arthroscopic treatment of such tears. Some clinicians have postulated that hip labral injuries are similar to knee meniscal injuries in that the resulting incongruity of joint motion, subtle subluxation, and abnormal joint loading could predispose athletes to early arthritic changes of the joint.
Return to Action
Before athletes return to running or other fast-paced activities, they should have restored strength equal to the uninjured side. After surgical repair, depending on the demand of the sport and the degree of preoperative deconditioning, a return to competitive athletic activities could take up to six months.
ADDUCTOR CANAL SYNDROME
Common Causes
This syndrome involves compression of the superficial femoral artery at the level of the adductor canal (Hunter’s canal). The canal also contains the femoral vein, branches of the femoral nerve to the vastus medialis muscle, and the saphenous nerve. Compression of the artery, as well as the vein and nerves, may occur and can be due to pressure from an abnormal musculotendinous band that arises from the adductor muscle mass. This might be either congenital or acquired as a result of a prior injury such as a kick to the inner thigh in soccer or another sport. The condition can also be produced by significant hypertrophy of the surrounding medial thigh muscles due to excessive resistance training, which then compresses this canal and its contents. This syndrome is very rare but is more common in young and athletic individuals.
Identification
Athletes with this syndrome report worsening lower leg claudication (leg pain with exertion) and fatigue from the diminished blood supply by compression of the femoral artery. This discomfort, which is exacerbated by activity, is often relieved by rest. During physical exam, pulses are normal at rest but may be diminished or absent in the involved extremity when symptoms are present. When the saphenous nerve is compressed, the athlete may experience burning paresthesia, which is an electrical shock-like sensation or numbness along the distal medial thigh and calf, possibly extending to the medial foot. Diagnostic ultrasound vascular studies at rest and immediately postexercise when symptomatic may help identify vascular compromise. Alternatively, arteriography is used to diagnose the occlusion of the superficial femoral artery at the Hunter’s canal.
Treatment
Treatment involves surgical excision of the musculotendinous band compressing the femoral artery. If damage to the arterial wall has occurred, vascular repair might also be required. If focal hypertrophy of surrounding medial thigh muscles is deemed to be a cause, modification of resistance training is recommended. Following surgery, a rehab program can be established that includes stretching, strengthening, and exercises to build endurance.
Return to Action
Return to sport depends on which and how much surgery has been done. Retraining can begin anywhere from two weeks to three months postsurgery and is overseen by the surgeon, the physiatrist if part of the treatment team, and a physical therapist.
PELVIC STRESS FRACTURE
Common Causes
Due to the great forces that are transmitted through the lower extremities during impact activities such as running and jumping, the pelvis is susceptible to stress fractures. The injuries are due to repetitive stresses of the powerful thigh muscles acting upon their attachment to the pelvic bones as well as directed transmitted forces through the bones. Stress fractures of the pelvis often occur at the pubic rami (a group of four bones in the front of the pelvis), the neck of the femur, and the acetabulum. Females with anorexia, inadequate nutrient intake, relative energy deficiencies with prolonged exercise, and deficiencies in bone mineralization related to prolonged periods of amenorrhea are most vulnerable to pelvic and hip stress fractures. Males with low testosterone and similar nutritional deficiencies are also considered to be at risk for these fractures, albeit they do happen with less frequency in male athletes. These injuries often occur in long-distance runners and other endurance sports.
Identification
Many stress fractures go undetected when athletes opt not to seek treatment for such nonspecific pains that usually improve with rest and analgesics. Complaints include pelvic and groin pain that gets worse with activity. Symptoms improve with rest. Many times, exacerbations are associated with an abrupt increase in training activity. Pain over the anterior pelvis, particularly at the attachment of muscles, may indicate a pubic stress fracture. Groin pain with hopping and prolonged running may be present. X-ray can detect stress fractures occasionally, but bone scan or MRI is more reliable.
Treatment
The first measure in treatment is to identify the offending activities and decrease or eliminate them. Other exercise activities may be continued with the guidance of a knowledgeable trainer, physical therapist, or physician. Treatment includes relative rest, and at times a limited period of no or partial weight bearing with crutches or a walker. Nonsteroidal anti-inflammatory medications should be used sparingly for a short period, because long-term use may delay fracture healing. Nutritional and hormonal deficiencies should be corrected. If stress fractures recur, a thorough metabolic workup is necessary. In females, bone density studies are recommended to assess underlying osteopenia or osteoporosis. Female athletes with stress fractures should be screened for the female athlete triad as an underlying etiology; the triad includes amenorrhea, osteopenia or osteoporosis, and poor diet or disordered eating. If the triad is suspected, the athlete should be referred for medical and nutritional counseling and if a behavioral issue is identified (exercise addiction or obsession, anorexia or other behavioral concerns), psychological counseling is warranted.
Return to Action
Athletes can usually return to action in four to six weeks after injury. Activity should be ramped up gradually with modification of the regimen responsible for the damage. Preparation for return to sports should focus first on strengthening exercises and then on progressive increases in weight-bearing activities. Running mileage should start at 20 percent of the preinjury total and gradually increase over the course of the recovery period, usually several months.
PELVIC AVULSION FRACTURES
Common Causes
Avulsion is the act of pulling or tearing away, and an avulsion fracture occurs when a fragment of bone tears, or breaks, away from the main bony mass as a result of a great pulling force, seen usually at tendinous points of insertion. Adolescents are primarily affected by pelvic avulsion fractures, which commonly occur at three distinct bony points. The first point is the anterior superior iliac spine (ASIS; the palpable bony prominence at the front and top of the iliac crest) where the sartorius tendon attaches. Jumping sports such as basketball or volleyball can cause strong contractile force through the sartorius, which can lead to avulsion fracture. The second point, the anterior inferior iliac spine (AIIS; a bony prominence at the front part of the hip just below the ASIS), can be avulsed by forceful hip flexion contraction by the rectus femoris muscle. Kicking sports such as American football or soccer can cause avulsion fractures where the rectus femoris, one of the quadriceps muscles, attaches to the ASIS.
The third common area in the pelvis to have associated avulsion fracture is the ischial tuberosity (the sit bone). Running sports may cause extreme pulling force at the hamstring tendons as they insert on the ischial tuberosity (the bony portion of the pelvis we sit on), leading to avulsion fracture. These ischial avulsion fractures are common in sprinting activities in which runners work to extend their legs into the ground fast and forcibly in order to quickly reset for the next sprint push-off. They are also seen in other sports in which athletes tend to land hard on a single limb, such as in planting the foot for a change of lateral direction or “juking” to elude a would-be tackler.
Identification
Symptoms of avulsion fracture include sudden onset of pain localized focally to the area of injury. Often the acute pain is associated with an audible snap or pop. Tenderness to the touch occurs over the fracture, and pain is elicited by range of motion of the hip whereby pulling or stretching occurs at the avulsed fragment. Active contractile activity of the affected muscle and respective tendon will also induce pain.
Treatment
Treatment of fractures to the front part of the hip (ASIS, AIIS) is conservative with analgesics, ice, and activity restriction until the fracture heals. Surgery appears to offer no advantage. Some controversy exists concerning appropriate treatment of ischial tuberosity avulsion fractures (posterior aspect of the hip). Complications such as strength deficits and callus formation with pain have been reported with larger ischial tuberosity avulsions. Some physicians suggest that large fragments that are displaced more than 0.4 to about 0.8 inches (1 to 2 cm) should undergo early surgical repair; however, assuming the avulsed fragments remain stable, most ischial tuberosity avulsion fractures are treated similarly to the other injuries.
Return to Action
Athletes may return to their sport once they have recovered passive and active range of motion and strength in the associated muscles, and have noted healing of the fracture with bony callus formation seen via imaging. Isokinetic testing can be used to accurately compare strength, and X-rays can assess maturing callus. Return time can vary greatly based on severity, but generally two to four months can be expected.
SNAPPING HIP SYNDROME
Common Causes
A snapping hip can be caused by several processes that result in the characteristic snapping sensation described by an athlete. This snapping sensation can be painless or can elicit a quite painful response. As the source can be either extraarticular (outside of the hip joint) or intraarticular (inside of the hip joint), the athlete can describe feeling the snapping either at points around the hip or can have the sensation within the hip itself. Snapping hip can occur in any athlete during activity or when the hip is put through its range of motion, especially if flexion-to-extension movements also include an internal-to-external rotation movement at the hip. It is most often seen in runners, triathletes, cheerleaders, dancers, and rowers.
While there is no debate that the extraarticular causes are more common than the intraarticular etiologies, there is some debate on which of the two extraarticular snapping syndromes is most common. The first occurs when snapping results from the ITB (the muscle along the outer part of the thigh) moving over the bony prominence of the greater trochanter (the bump on the outer side of the hip; more specifically on the outer side of the femur, or leg bone). The second is when the iliopsoas tendon snaps over the pectineal eminence of the pelvis (the bony prominence on the portion of the pelvis where the femur, or thigh bone, connects). With all these conditions, motion creates a “bowstring” effect, causing a palpable snap that is often both visualized and audible. The most common causes of intraarticular snapping include acetabular labrum tearing and intraarticular loose bodies.
Identification
Extraarticular snapping may be felt over the greater trochanter with passive movement of the hip or while walking. A trainer can walk with the athlete with a hand over the greater trochanter to detect any snapping. Examination involves rotation of the hip while held in an adducted position to feel the ITB snapping over the greater trochanter. Snapping at the iliopsoas can be felt by placing the hand on the iliopsoas tendon, located medial (toward the midline of the body) to the ASIS and just below the inguinal ligament, and asking the athlete to flex the hip, followed by internal rotation and adduction (bringing leg closer to the midline of the body) and then hip extension. Pain, if present in either case, will occur upon the snapping of the ligament over the bony prominence. Snapping from intraarticular pathology will likely cause gait abnormalities and pain with weight bearing because it will be the hip joint itself that is inflamed.
Irritation at the site of tendon and bone friction can create an acute bursitis or, chronically, a bursopathy. Secondary trochanteric bursitis causes tenderness over the greater trochanter and pain during lying on the affected side. Secondary iliopsoas bursitis will cause tenderness over the anterior hip and be painful with hip range of motion. If an athlete has significant pain or perceived instability with hip range of motion, diagnostic imaging with X-ray should be performed to rule out intraarticular bone fragments. X-ray can be helpful in intraarticular etiologies but has little value in extraarticular diagnosis. Ultrasound and MRI are the best imaging modalities for extraarticular causes, while MRI is also the best to evaluate for intraarticular tear of the acetabular labrum. Dynamic ultrasonography can effectively visualize extraarticular snapping.
Treatment
Treatment for snapping hip focuses on stretching the tight tendons, ITB, or hip capsule (or more than one of these), as well as strengthening the hip abductors and adductors, hip flexors, and tensor fasciae latae. The goal is to correct the pathologic mechanics leading to the mechanical snapping. This is best accomplished with formal physical therapy followed by compliance with a home exercise program. If there is pain, the athlete should rest and avoid activities associated with the snapping. Anti-inflammatory medications might be helpful for pain or associated bursitis. Persistent problems might require a corticosteroid injection into the bursa or region of snapping. Recalcitrant snapping hip problems may lead to tendinosis or tendon tearing and have an eventual need for percutaneous tenotomy or orthobiologic implementation, or require surgical repair. Injections and percutaneous tenotomy have increased accuracy with concomitant use of ultrasound visual guidance.
Return to Action
With an aggressive and consistent stretching and strengthening program, most athletes will be less symptomatic and ready to return to activity in two to four weeks. Failure to improve in that time frame warrants further workup or treatment as well as continued avoidance of irritative activities and sports.
HIP POINTER
Common Causes
Hip pointers (also known as iliac crest pain) are contusions that occur along the pelvis, particularly the iliac crest anterior and lateral hip area. This injury is generally caused by direct trauma to the iliac crest caused by another player, such as being struck by a helmet in American football, kicked by a foot in soccer, checked by a lacrosse stick, hit by a pitch in baseball, or colliding with a hard playing surface (checked into the boards in hockey, tackled onto frozen turf, pushed to the basketball court, or sliding forcefully in baseball).
Identification
The hallmark symptom of hip pointer injuries is focal pain along the bony iliac crest, usually on the lateral side of the pelvis where it is covered by very little soft tissue. Hip pointers can also occur at any of the other bony prominences around the pelvis. Typically, pain will occur immediately after acute injury; but upon further examination, the injured athlete may report pain with resisted trunk rotation or resisted ipsilateral hip abduction (moving the leg out laterally away from the midline), or while doing sit-ups or other abdominal contractile actions (like sneezing or coughing). Swelling and bruising over the injury site may indicate a more significant injury. Significant irritation to touch and severe bruising can suggest an underlying fracture and warrants prompt referral to a physician for diagnostic evaluation. Imaging is typically not needed, but in more severe cases, diagnostic imaging would be useful in determining which structures are affected and to what degree, and can rule out a fracture. At the point of care, ultrasound can be used to look for hematoma, tears at the tendinous insertion, or muscle defects. Magnetic resonance imaging may be suggested in the most severe cases. Note that diagnostic lidocaine (local anesthetic) injection to the point of maximal pain can also be diagnostic.
Treatment
Initial treatment includes prompt application of ice, alternating five minutes on and five minutes off, for 30 to 40 minutes four times per day. These applications should continue for 72 hours as needed for pain and to control superficial swelling and hematoma formation. A compression wrap should be worn between applications. Gentle stretching of the hip muscles follows unless there is extensive bruising, in which case it is deferred for up to one week. Muscle spasms should be considered and addressed. Treatment by an athletic trainer or physical therapist might then include range-of-motion and strengthening exercises, as well as other modalities such as electrical stimulation, the Graston Technique, and, when safe and applicable, therapeutic ultrasound wave or heat exposure.
Occasionally, hip pointers are so severe that they make walking very painful. In such cases the use of crutches for protected weight bearing on the affected limb for a week or so often proves helpful. If extensive bruising occurs and a large hematoma is suspected, the athlete should be evaluated by a physical medicine and rehabilitation physician (physiatrist) or orthopedist. Large hematomas might benefit from early aspiration (withdrawing the pooled blood with a needle and syringe) to reduce tissue distension, promote more complete resorption, and speed healing.
Return to Action
Simple, small hip pointers might resolve within one week to allow comfortable weight bearing and full pain-free range of motion of the hip and trunk. In such cases, athletes may immediately return to play. More severe hip pointers, particularly those with associated hematoma formation or small tears of the surrounding muscle, can take two to four weeks to heal to the extent that motion is pain free and strength is returned to surrounding muscle. The affected iliac crest should be protected by viscoelastic or other compression-resistant padding for one month or so following the injury. On a limited basis (game day only), use of a long-acting anesthetic agent injected into the painful region might allow return to play earlier without risking much further injury. This is not recommended for high school athletes.
OSTEITIS PUBIS AND ATHLETIC PUBALGIA
Common Causes
Osteitis pubis is an inflammatory or degenerative condition of the pubic symphysis, the juncture where the right and left pubic bones meet in the front of the pelvis. Athletic pubalgia is another cause of pain in this region and is related to strains or tears of numerous tendons or weakness of musculature that attaches and acts on the pelvis, causing instability. Osteitis pubis and athletic pubalgia can occur independently, or one condition can influence the development of the other. Athletic pubalgia is a painful condition, but the degenerative changes of the pubic bones of osteitis pubis may or may not be painful.
Osteitis pubis and athletic pubalgia are frequently seen in athletes who play contact sports such as American football, rugby, and hockey and noncontact sports such as soccer, cross country running and cross-country skiing, and figure skating. Athletic pubalgia is also seen in tennis, squash, and basketball players and, more rarely, swimmers.
The cause of injury in osteitis pubis is likely repetitive stress and shearing at the pubic symphysis when the pelvis is briefly supported on one leg and the other leg is swinging forcefully, such as when kicking a soccer ball or football, sprinting or cutting while running, or during hockey or skating and jumping in figure skating. Impact to the pubic symphysis by a helmet and compression of the pubis by a forceful tackle or a fall on one side are also possible causes of injury.
Athletic pubalgia is believed to arise more commonly in elite athletes who suffer strains or tears to the tendons that attach the abdominal muscles to the front of the pelvis, primarily the rectus abdominis tendon. This tendon might be injured through repetitive combined trunk rotation on an abducted and extended hip, such as during swinging a bat, or by a single forced extension (backward bending) of the trunk, for example, when a running back is tackled full-on while changing direction (cutting) or when a quarterback has the back leg planted and is brought down by a head-on tackle. Similar trauma can occur when a hockey player is skating quickly toward the opposing goal and is forcefully “stood up” when checked by an opposing player.
Identification
Osteitis pubis, when symptomatic, is indicated by a gradual onset of focal pain localized over the pubic symphysis. The pain might be accompanied by slight swelling, but rarely any bruising unless the onset is associated with a direct blow to the region. Injured athletes with this condition report pain during attempts to walk briskly, jog, or run, and particularly with resisted hip adduction (the athlete attempts to cross the legs, and the physician, trainer, or therapist attempts to push the legs apart). They also feel pain when lying on their back when they lift one leg up against resistance. All these maneuvers place strain on the injured pubic symphysis, causing the pain.
Athletes with athletic pubalgia typically have an acute, rather than gradual, onset of discomfort in the mid to lower abdominal region initially; if left untreated, they might begin to experience pain in either medial thigh and or inguinal (groin) regions. One theory suggests that tears of the abdominal rectus muscle tendon weaken and redistribute the balance of support that the abdominal and hip girdle muscles have on the stability of the pelvic joints, thereby causing the adductor longus, gracilis, and other hip girdle and lower abdominal muscles to strain to maintain pelvic stability. In rare cases, pain radiates to the perineum, the region between the genitalia and anus. Performing resisted hip adduction, double-leg lifts, or resisted trunk rotation will replicate the pain. Only 25 percent of athletes with athletic pubalgia have concurrent tenderness over the pubic symphysis, and 33 percent experience tenderness along the inferior portion of the pubis where the adductor tendons insert. On examination by a physician, the injured athlete might have pain and tenderness along the inguinal canal, but rarely is a true hernia found.
Diagnostic tests might include X-rays, which could reveal degenerative changes of the pubic symphysis indicative of osteitis pubis, or concurrent hip OA, another cause of groin and medial thigh pain. Magnetic resonance imaging of the pelvis might reveal asymmetry or strain of the abdominal rectus muscles, inflammation or tear of the distal rectus abdominis tendon and tearing of the conjoint tendon of the rectus abdominis and adductor muscles, irregularity or inflammation of the pubic symphysis, and other nonspecific findings, which when correlated could provide helpful information.
Treatment
Initial treatment for both osteitis pubis and athletic pubalgia involves rest from the offending activities (forceful side-to-side kicking, trunk rotation to extremes, sprinting, and jumping), acetaminophen or ibuprofen, and either intermittent ice or warm packs, as comfort dictates. This conservative treatment should last for up to 7 to 10 days. If the athlete is still in pain after that time, formal rehabilitative therapies should be started by a certified athletic trainer or registered physical therapist, or as prescribed by a physician.
Physical modalities such as ultrasound with concurrent stretching of the adductor muscles and the hip joint might help restore flexibility and motion to these structures, thereby reducing pull on the pubic symphysis and lower abdominal muscles. Interestingly, therapeutic massage can be helpful for these conditions, presumably by further stretching of the fasciae and muscle, resetting the stretch reflex, and reducing edema in the affected muscles. Should symptoms persist, a corticosteroid may be injected into the pubic symphysis in the case of osteitis pubis or to the proximal adductor tendon sheath on the lower portion of the pubic bone in the case of athletic pubalgia. A diagnostic lidocaine injection under ultrasound guidance may help identify any of the potentially overlapping pain generators.
If a torn or detached conjoint tendon is identified by diagnostic ultrasound or MRI, the PRP injection with ultrasound guidance may be considered.
Initial rehabilitative therapy may include stationary cycling, water walking or water jogging, and walking on level ground. When the athlete can perform resisted hip adduction exercises on several consecutive days without immediate or residual next-day pain, then strengthening and balancing of the hip girdle and abdominal muscles may begin. Athletes begin initial strengthening exercises in a neutral position (hips and trunk aligned with no rotation) and both feet supported on the ground or training equipment. These exercises are followed by exercises allowing the limb off the ground. Finally, running, cutting, and sport-specific training are added in succession as strength allows. The treating health care professional should take care to assess the entire leg from foot to hip and the abdomen and spine for strength, range of motion, and flexibility deficits because any weakness along this course (the kinetic chain) might result in persistent or recurrent injury.
If athletes do not respond favorably to the treatment regimen described within six to eight weeks, they should receive a thorough medical examination to rule out other causes of pain, including genitourinary infections, colorectal tumors, and occult hernias in either sex; endometriosis, ovarian cysts, or benign or cancerous uterine or ovarian tumors in women; and prostatitis or prostate or testicular tumors in men.
In rare instances in which the degenerative changes of osteitis pubis result in such significant instability of the pubic symphysis, a pelvic strap-like brace may provide some symptomatic relief. Only the most severe of conditions may require surgical fusion. In cases of athletic pubalgia resistant to conservative treatment measures, referral to a general or orthopedic surgeon experienced in this condition is warranted for possible surgical repair, elongation, and reattachment of weakened rectus abdominis and pelvic floor musculature. For persistent medial thigh pain, an epimysial release of the adductor longus muscle (firm connective tissue that surrounds the muscle) can also be performed. Early ambulation should begin the day of surgery, and reconditioning exercises may begin in the weeks to follow. All surgeons have their own specific protocols for rehabilitation depending on the findings at time of surgery and the confidence in their repair.
Return to Action
Return to play is permitted when the athlete achieves a pain-free state both at rest and throughout each stage of the rehabilitative course. The athlete must be able to perform every aspect of the specific sport in practice at full effort before being allowed to return to competitive play. Rehabilitative efforts should extend beyond the return-to-play date to maximize core and hip girdle strength in hopes of preventing a recurring injury.
COCCYGEAL FRACTURE
Common Causes
The coccyx, commonly called the tailbone, is composed of four fused segments and is attached to the lowest portion of the sacrum by the sacrococcygeal ligament and to the pelvis by the sacrospinal ligaments. The coccyx maintains motion (albeit minimal motion) through a flexible fibrocartilaginous connection between itself and the sacrum. The coccyx is rarely injured except through direct trauma, such as falling onto a hard surface in the sitting position and landing squarely on one’s buttocks or when one is struck by a swift-moving object such as a lacrosse ball, baseball, hockey puck, or shoe. A coccygeal fracture is not uncommon in gymnasts who fall onto the edge of a bar or balance beam, or in cyclists who hit their tailbone on the bar of the bike.
Identification
Fractures of the coccyx are generally associated with injury to the connecting sacrococcygeal ligament. Fractures might be initially missed by X-rays because the fracture segments might not be displaced. Magnetic resonance imaging or a CT scan can provide a definitive diagnosis of fracture and surrounding soft tissue injuries but is rarely needed unless pain symptoms persist for over a month. Dislocation of the coccyx also occurs due to trauma and may be seen clearly on X-ray. At the time of injury, athletes with a coccygeal fracture or dislocation will have moderate to severe pain along with bruising and swelling. Initially, simple walking can prove difficult because of pain, but this generally subsides within a day or so. The injured athlete is then left with pain in the region while sitting on firm surfaces or when pivoting at the hips. Some also find it painful to pass a large or hard stool for a few days or to wipe the rectum after a bowel movement. Wearing a male dancer’s belt and tight leotard can irritate this injury. Intercourse may also be temporarily uncomfortable.
Treatment
Treatment of this condition aims at reducing pain and swelling with ice compresses and over-the-counter pain relievers. Sitting with weight more forward on the ischial tuberosities or on a pillow, an inflatable donut, or a foam wedge with a relief cut out beneath the coccyx will be more comfortable than normal sitting. Sitting slumped backward tends to cause pain. If symptoms last longer than four weeks or continue to get worse, the athlete should see a physician. Persistent cases might benefit from an injection of a corticosteroid and lidocaine. Manual therapies (via rectal exam) can be done to realign a malaligned coccygeal segment. This technique may be extremely helpful in reducing pain. Only in the most stubborn chronic conditions should the athlete be referred to a surgeon for possible coccyx excision.
Return to Action
Return time is based solely on the athlete’s tolerance to the pain. As long as the athlete does not repeat the same kind of fall, this injury will not be exacerbated by athletic activity.
SPORTS HERNIA
Common Causes
Sports hernia is a condition characterized by chronic groin pain caused by weakness of the posterior inguinal wall. The onset is usually slow and gradual, delaying diagnosis and treatment. Sports hernia is believed to have multiple causes, including shear forces across the pelvis, overuse, and muscle imbalance. Sports hernias are caused by a weakness in specific muscles within the abdomen. Even athletes with strong abdominal muscles are subject to a potential sports hernia because the hernia does not result from weakness in the thick muscle tissue, the rectus abdominis, but rather from abdominal wall tissue that is too thin. Confusion often exists between athletic pubalgia and a sports hernia. Specifically, a sports hernia occurs through a defect in the transversalis fascia or the conjoint tendon. Athletic pubalgia occurs because of a weakness of the rectus abdominis. The constant pulling, jumping, and twisting that occur in sports apply a repetitive stress on these congenitally thin tissues and may lead to a herniation or protrusion of tissue inside the lower abdomen. For instance, a defect in the transversalis fascia (the posterior barrier in the inguinal region) can allow the bladder or bowel to protrude or push forward into the inguinal area.
Identification
Symptoms associated with sports hernia include gradually worsening lower abdominal or groin pain that might be confused with an adductor strain. In males, pain may be present in the testicle, commonly due to injury to the ilioinguinal nerve in the pelvic area. This nerve lies on the transversalis fascia and stretches when this tissue is stretched. Pain is exacerbated by kicking, running, cutting, or jumping and can radiate along the inguinal ligament, rectus muscles, adductors, and testicles. Valsalva, such as with a cough, sneeze, or bowel movement, can worsen symptoms. Athletes might have tenderness of the groin and spasm of the adductors.
While many people think of a hernia as having a palpable mass that can be felt during coughing or bearing down, this is not always the case. More often, the mass is not palpable at all. A doctor must evaluate the symptoms and perform tests to rule out other potential causes of the symptoms before arriving at a diagnosis of sports hernia. An ultrasound is commonly used to diagnose a hernia.
Treatment
Conservative treatment of sports hernias with PRICE and gradual return to activity are usually unsuccessful. Physical therapy can sometimes be helpful. If these conservative measures fail, surgical intervention can be considered. Surgical repair results in about 90 percent of athletes returning to full activity. Operative repair involves open or laparoscopic exploration with repair of the posterior inguinal wall defect. After surgery, stretching and strengthening regional muscle groups are imperative.
Return to Action
After surgery, athletes may return to sports once cleared by the operative physician. Return time varies widely, depending on the extent of surgery. Athletes might miss as little as six weeks and as much as six months of participation. Most athletes can return to action about six to eight weeks after surgical correction of the hernia. There should be only minimal discomfort, if any, upon return to activities.
SACROILIAC JOINT INJURY
Common Causes
The sacroiliac joint is made up of the sacrum (the lowest segment of the spine), which forms a joint with each of the adjacent iliac bones (the “wings” of the pelvis). The joint is held together by a very strong and diffuse complex of ligaments, which make the joint extremely stable. Injury to the sacroiliac joint might occur with an abrupt single trauma, such as missing a landing while skateboarding, snow skiing, or skating; being struck by a helmet in American football; or through repetitive trauma, such as in long-distance running, cross-country skiing, or rowing.
Identification
The sacroiliac joint helps transfer, absorb, and distribute the forces of impact from the ground that travel up through the leg and hip to the pelvis, and on to the spine. During the act of running, several times the body’s weight is generated in upward force each time the heel strikes the ground. Despite the partial absorption of these forces by the muscles and joints of the foot, leg, and thigh, there are still considerable forces acting across the sacroiliac joint. With repetitive activity, strain and injury to the ligaments and joint itself can occur. Injury can also occur to the sacroiliac joint when it is forced to bear heavy weight, such as while performing squats, or when subject to long-lever torsion stresses, as in lunging or hurdling and the sweeping high kicks of martial arts. Direct trauma to the joint is more likely to damage the joint surface, precipitating early OA, and less likely to cause disruption of the ligaments, although minor malalignments can occur. Pregnant women (who have high levels of the hormone relaxin, which increases the elasticity of the pelvic ligaments in preparation for the delivery of a child), and individuals who have a hereditary hyperlaxity syndrome are more susceptible to injury of the sacroiliac joint.
The pain of this injury is usually located on one or both sides of the sacrum, just lateral to the central crease of the buttocks. The pain is usually dull but can be sharp if the injury is acute and might radiate through the buttock and back of the thigh, even rarely continuing to the top of the posterior calf. Pain might also radiate around the thigh to the outer (lateral) portions of the groin. Unlike the pain of a pinch or inflamed lumbar nerve root, which has an often similar pattern of radiation, this pain is not associated with any numbness, tingling, or weakness other than pain-limited strength. Symptoms are generally worse with prolonged sitting and motions that cause the spine to extend (backward bending) because these increase load on the joint. The injured athlete might point to a small skin dimple (dimple of Venus) on the painful side of the sacrum or buttocks as the most painful spot in this condition. Unless the joint itself suffers direct trauma, bruising and swelling of the overlying soft tissues are frequently absent. In acute cases, pain can be exacerbated by hopping on the leg of the affected side or by brisk trunk and hip motions.
Treatment
Treatment of sacroiliac joint injuries begins with assessing the extent of injury to the joint and surrounding tissues. If the athlete cannot stand alone on the leg of the injured side of the joint without excruciating pain, or if extensive swelling or bruising occurs, the athlete should be evaluated immediately by a physician (because an underlying fracture of the sacrum or iliac bones might have occurred). If the athlete has associated numbness or tingling to the genital or rectal area or the lower leg, an injury to the adjacent lumbar spine or sacral nerve roots should be suspected; again, the athlete should see a doctor. In the absence of these symptoms, apply ice compresses for up to 20 minutes each hour for the first 72 hours and use acetaminophen or ibuprofen as needed. If running or other impact activities are the suspected cause of the injury, the athlete should avoid these activities until walking is pain free.
At this juncture, gentle stretching of the hip girdle muscles can begin to address flexibility deficits in the legs and pelvis and strength imbalance of the thigh and hip muscles, both of which adversely affect the function of this joint. Take care not to use the legs as long levers to stretch the hip girdle (sitting with legs stretched and feet resting on a stool or coffee table) because this puts too much strain on the joint. This also applies to the use of ankle weights, which when coupled with the length of the leg generates considerable strain on the sacroiliac joint. Hip girdle strengthening (including exercises such as bridges with the hips and spine aligned in neutral and planks) is excellent for strengthening the surrounding muscles.
If symptoms persist for a few weeks, the athlete should see a physician who is skilled in manipulation (osteopathic, allopathic, or chiropractic) or a physical therapist experienced in manual therapies. Such therapy can help in correcting any underlying malalignment, leg-length discrepancies, or associated muscular pain or spasm. In cases of hyperlaxity of this joint, the use of a sacroiliac joint compression belt might prove helpful in reducing symptoms and maintaining alignment. Should pain persist despite these measures, a sacroiliac joint corticosteroid and anesthetic may be injected with either ultrasound or X-ray guidance to reduce pain and inflammation. Rarely, in chronic cases of this condition in which joint laxity persists, the image-guided injection of agents to purposely scar and tighten the ligaments (prolotherapy or sclerotherapy) is helpful. In instances of severe disruption of the joint, surgical fusion might be necessary, but such cases are rare.
Return to Action
Return to sports following a sacroiliac joint injury depends on symptoms when at rest and on the gradual gains made through prescribed exercise. Generally, flexibility deficits and strength imbalances should be corrected before the athlete attempts a return. Once the athlete can do sport-specific activities without postexercise or delayed-onset pain, a return may be initiated. Runners and rowers should gradually work up to their preinjury distances over a course of weeks rather than days. Weightlifters should gradually increase their weights and should avoid single-leg squats for no less than a month after achieving a pain-free state. A sacroiliac joint belt or taping techniques might prove helpful initially for instability-related pain, but they cannot be counted on to reliably protect the sacroiliac joint from injury during running or other impact activities.
PELVIC NERVE INJURY
Common Causes
A traumatic blow to the abdominal wall sustained in a contact sport such as American football or rugby can cause an injury to one of a group of nerves, commonly grouped together as the pelvic nerves. Common examples of these include the iliohypogastric, ilioinguinal nerve, and genitofemoral nerve. Athletes may have symptoms directly after the trauma, depending on the force of the blow or direct neural injury, or symptoms might begin after the injury as tissue scarring or fibrosis develops, which then irritates the nerve. Less common nerve entrapments causing hip pain involve the cluneal nerves of the posterior buttocks and the lateral cutaneous nerve of the thigh (LCNT, previously known as the lateral femoral cutaneous nerve, or LFCN).
Identification
Symptoms of ilioinguinal nerve injury include burning pain over the lower abdomen that might radiate down the thigh and into the genitalia. Symptoms of iliohypogastric nerve injury include burning pain over the hypogastric area (area between the belly button and the pubis). Tenderness of these nerves as they pass medial to the ASIS might occur. A genitofemoral nerve injury can cause numbness or burning of the medial thigh or genitalia. Symptoms for this might be exacerbated by extension of the hip or thigh. Maintaining a flexed posture can alleviate these symptoms. Lateral cutaneous nerve of the thigh injury can cause numbness or burning of the anterior lateral thigh, with possible tender point at the ASIS or in the sartorial sling (myofascial sling formed between the sartorius and the tensor fasciae latae). Cluneal nerves innervate the cutaneous buttock, and irritation to these may lead to pain or numbness, causing gluteal–buttock pain. For definitive diagnosis, nerve blocks may be required and can be completed with injections based on anatomic landmarks and knowledge of normal anatomy, or for more increased accuracy, can be completed with ultrasound location of the nerve and then sonographic guidance of the injection.
Treatment
As is true of most nerve injuries, treatment consists of restricting activity and resting to allow time for recovery. Trying to return too soon might cause more significant nerve damage. Topical applications such as a lidocaine patch might be helpful when placed over the region of burning pain. Symptoms of iliohypogastric or ilioinguinal and LCNT injuries can be alleviated with a perineural cortisone injection. Due to the precision needed to deliver these injections, in order to have good effect and keep from injuring the nerve further or damaging surrounding structures, ultrasound guidance is preferred. In rare cases, surgical release of the nerve from surrounding compressive tissues might be required. Newer options have arisen, including peripheral nerve stimulators, placed under image guidance; however, these are yet to be sufficiently studied and are not the norm with regard to treatment coordination.
Return to Action
Athletes can return to play as their symptoms allow. Time to return varies according to severity of injury, but athletes should safely assume recovery to take four to six weeks. If pain persists and surgical decompression, or other intervention, is performed, the athlete may be sidelined for up to three months. Conservative and postoperative rehabilitation focuses on range-of-motion exercises and core strengthening.
*The authors would like to acknowledge the contribution of Ferdinand J. Formoso to this chapter.
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