Iliac apophysitis is an overuse related traction injury affecting the iliac crest apophysis. The iliac apophysis closes on an average round 17 years of age. It is most commonly seen in long-distance runners and skaters. It has been reported in hockey, lacrosse, and football players. The exact incidence in not known.
The athlete presents with a history of gradual onset of pain over the iliac crest while running. In contrast, the athlete with an acute traumatic avulsion injury of the iliac crest or the anterior superior iliac spine will present with a sudden onset of severe pain. In athletes with iliac apophysitis, there is no history of direct impact trauma to the iliac crest. Pain is exaggerated by abduction of the hip against resistance. Tenderness is localized over the iliac crest.
Treatment is symptomatic with local ice, pain medication if needed, and modification or rarely complete cessation of the offending activity in some athletes. Resolution of symptoms gradually occurs typically over a period of 4 to 6 weeks. Once pain-free and normal examination, the athlete can resume unrestricted sport participation.
Osteitis pubis is characterized by symphysis pubis pain, and chronic stress related changes in the subchondral bone, reported most commonly in athletes participating in soccer, ice hockey, basketball, and running. The condition has also been reported in fencing, Australian rules football, and cricket.
Overuse related stress affecting the symphysis pubis is believed to be the cause for development of osteitis pubis. The exact mechanism is not known; however, it is believed that repetitive shearing forces accompanying side to side and up and down movement at the pubic symphysis predisposes to osteitis pubis. These types of movements can occur in sports requiring sudden change in direction, running, kicking, acceleration, or deceleration. Forceful contractions of hip adductors can also pull on the pubic symphysis.
There is an insidious onset of pain over the symphysis pubis area or groin exaggerated by continued activity, and there is localized tenderness over the symphysis pubis. Athletes may also report pain in the thigh, hip, or perineum. Pain is aggravated by running, kicking, pivoting, sudden acceleration, and deceleration. Soccer players adapt to avoid certain kicks that cause the most pain. Pain can be reproduced or exacerbated on examination by having the athlete adduct the hip against manual resistance or passively abduct the hip. Osteomyelitis affecting the pubis symphysis must be considered in the differential diagnosis. Other causes of groin pain in young athletes are noted in Table 25-1.1–4 Differentiating features of some hip conditions are summarized in Table 25-2.1–6
Musculotendinous strains—adductor strain, iliopsoas strain |
Bursitis—iliopectineal bursitis, ischial bursitis |
Stress fractures—femoral neck, proximal femur, pubis ramus |
Hip disorder—SCFE, septic arthritis, inflammatory arthritis |
Apophyseal avulsion fractures—ASIS, AIIS, ischial tuberosity |
Entrapment neuropathies—ilioinguinal N, obturator N, genitofemoral N |
Snapping hip syndrome |
Osteitis pubis |
Osteomyelitis of symphysis pubis |
Sports hernia |
Intra-articular pathology—acetabular tears, loose bodies |
Referred pain—lumbar spine and cord, abdominal, pelvic, genitourinary disease |
Diagnosis | History | Physical Findings | Differential Diagnosis |
|---|---|---|---|
Legg-Calvé-Perthes disease | Insidious onset (1–3 mo) of limp with hip or knee pain | Limited hip abduction, flexion, and internal rotation | Juvenile arthritis, other inflammatory conditions of the hip. Muscle strain, avulsion fracture |
Slipped capital femoral epiphysis | Acute (<1 mo) or chronic (up to 6 mo) presentation, pain may be referred to knee or anterior thigh | Pain and limited internal rotation, leg more comfortable in external rotation; chronic presentation may have leg length discrepancy | |
Avulsion fracture | Sudden, violent muscle contraction; may hear or feel a “pop” | Pain on passive stretch and active contraction of involved muscle; pain on palpation of involved apophysis | Muscle strain, slipped capital femoral epiphysis |
Hip pointer | Direct trauma to iliac crest | Tenderness over iliac crest, may have pain on ambulation and active abduction of hip | Contusion, fracture |
Contusion | Direct trauma to soft tissue | Pain on palpation and motion, ecchymosis | Hip pointer, fracture, myositis ossificans |
Myositis ossificans | Contusion with hematoma approximately 2–4 wks earlier | Pain on palpation, firm mass may be palpable | Contusion, soft tissue tumors, callus formation from prior fracture |
Femoral neck stress fracture | Persistent groin discomfort increasing with activity, history of endurance exercise, female athlete triad (eating disorder, amenorrhea, osteoporosis) | ROM may be painful, pain on palpation of greater trochanter | Trochanteric bursitis, osteoid osteoma, muscle strain |
Osteoid osteoma | Vague hip pain present at night and increased with activities | Restricted motion, quadriceps atrophy | Femoral neck stress fracture, trochanteric bursitis |
Iliotibial band syndrome | Lateral hip, thigh, or knee pain, snapping as iliotibial band passes over the greater trochanter | Positive Ober’s test | Trochanteric bursitis |
Trochanteric bursitis | Pain over greater trochanter on palpation, pain during transitions from standing to lying down to standing | Pain on palpation of greater trochanter | Iliotibial band syndrome; femoral neck stress fracture |
Avascular necrosis of the femoral head | Dull ache or throbbing pain in groin, lateral hip or buttock, history of prolonged steroid use, prior fracture, slipped femoral capital epiphysis | Pain on ambulation, abduction, internal, and external rotation | Early degenerative joint disease |
Piriformis syndrome | Dull posterior pain, may radiate down the leg mimicking radicular symptoms, history of track competition, or prolonged sitting | Pain on active external rotation, passive internal rotation of hip, and palpation of sciatic notch | Nerve root compression, stress fractures |
Iliopsoas bursitis | Pain and snapping in medial groin or thigh | Reproduce symptoms with active and passive flexion/extension of hip | Avulsion fracture |
Meralgia paresthetica | Pain or paresthesia of anterior or lateral groin and thigh | Abnormal distribution of lateral femoral cutaneous nerve on sensory examination | Other causes of peripheral neuropathy |
Degenerative arthritis | Progressive pain and stiffness | Reduction in internal rotation early, in all motion later, pain on ambulation | Inflammatory arthritis |
Early in the course, the x-rays are normal. X-ray may show local sclerosis 2 to 3 weeks after the onset of the pain, while a bone scan is positive early in the course. Other x-ray changes include subchondral microcysts, osteolytic lesions, joint widening, or narrowing (Figure 25-1). Instability at pubic symphysis may be detected with x-ray taken with athlete standing on one leg (Flamingo view). MRI scan is highly sensitive for early diagnosis.
The condition is self-limited with an excellent prognosis in young athletes for resolution of pain and return to full sports. A period of complete rest and judicious use of NSAIDs help alleviate the pain. Once pain is resolved, a program of stretching and strengthening of hip rotators, flexors, and adductors is initiated and maintained.1,5,7,8 Most young athletes on an average are pain-free within 6 months (ranging 3–12 months). Rarely, those with significant instability need orthopedic consultation and may need symphysiodesis (Box 25-1).
Stress fractures of the proximal femur occur more often in young military recruits subjected to repetitive overuse and excessive conditioning. In athletes, femoral stress fractures have been reported most commonly in competitive runners. Other sports with similar stress can also lead to stress fractures. Female athletes with pathogenic weight control behaviors and amenorrhea are at a higher risk.
Two types of femoral neck stress fractures are described, one affecting the inferior or medial side of the femoral neck or the compression type, and the other type affecting the tension or lateral side of the femoral neck or the distraction type.1,9–12 The underlying mechanism that results in stress fracture is repetitive microtrauma.
The young athlete will present with thigh, knee, or groin pain, which is worse with weight-bearing, and decreases with rest. Athlete may avoid weight-bearing on the affected side and have an antalgic gait. On examination, there is tenderness over the proximal femur and the groin. There may be limitation of hip flexion and internal rotation. There is an increased risk for similar stress fracture on the opposite side.
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