Hip Injuries

Michael M. Weinik, DO; Ian B. Maitin, MD; Ferdinand J. Formoso, DO

    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. Amenorrhreic 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 every athlete will have his or her 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 is difficult because the hip and pelvis are the coupling mechanism that transfers strength and power from the legs to the trunk and vice versa; they help absorb, dampen, and distribute the impact of running and jumping; and they provide 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.

ADDUCTOR TENDINOSIS

Common Causes
    Tendinosis of the lower limb is quite common in athletes because of the elevated level of strain exerted on this limb during many sports. Although traditionally categorized as a tendinitis, which implies an inflammatory process, many clinicians now regard these injuries as resulting from a degenerative process. Adductor 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 tendinosis 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 his or her movements, which leads to localized weakness at the injury site, which ultimately ends in loss of endurance. Lower-limb tendinosis tends to be sport specific, with most hip injuries occurring in kicking athletes, hockey players, gymnasts, and horseback riders.
 

Identification
    The diagnosis of adductor tendinosis 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 MRI might be useful in pinpointing the location and extent of injury.
 

Treatment
    Traditional treatment for tendinosis includes physical therapy, analgesics, anti­inflammatory 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. 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. As if treatment results were not grim enough already, another study (Akermark and Johansson 1992) 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, with the help of physiatry, 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 are available.

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. OA of the hip is typically a noninflammatory disease process characterized by destruction of the end of the femur bone as it attaches to the hip socket 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. The exact cause of these pathologic changes is uncertain, but physiologic and biomechanical factors such as age, obesity, genetics, joint alignment, joint laxity, 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. 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 located 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 in the hip muscles.
    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.
 

Treatment
    Treatment begins with a conservative regimen consisting of some or all of the following: lifestyle modification, physical therapy, nutritional supplementation, and pharmaceuticals. 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 targeted muscle strengthen­ing and improvement of coordination in conjunction with a stretching program can be quite effective in reducing symptoms. Use of heat and ultrasound at the affected region can also be helpful.
    Analgesic medications, predominantly nonsteroidal anti-inflammatory medica­tions (NSAIDs), are the mainstav 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.
    If symptoms continue despite conservative treatment, intra articular injection of cortisone (glucocorticoids) may be considered. According to the National Institutes of Health Consensus Conference, if moderate to severe symptoms or disability persist despite an extended course of nonsurgical management, total hip replacement is a reasonable option.
 

Return to Action
    After treatment with conservative measures as described for three to four weeks, the athlete can slowly return to sport activity while being closely monitored for return of symptoms. If symptoms recur, the athlete should refrain from the inciting activity and return to the conservative regime of relative rest, physical therapy, and medications. Unfortunately, no significant taping or bracing options are available to treat hip OA, which underscores the importance of strengthening the hip muscles and stretching.

GREATER TROCHANTERIC BURSITIS

Common Causes

    Trochanteric bursitis (bursitis of the hip) is relatively common, particularly in younger athletes. It includes inflammation of any or all of the bursae in the region. Bursitis of the 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. Hip bursitis is commonly seen in long-distance runners. Bur­sitis is often associated with other pathologies of the lower limb, such as osteoarthritis, 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 hip bursitis 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 bursitis 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 iliotibial band tightness should be evaluated, as well as precise measurement of the leg lengths.
 

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 (cortisone shots). For long-term success, both musculoskeletal and pharmacological treatments are usually needed. 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 osteoarthritis) 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 take care of the inflammatory process. For these athletes it is necessary to perform a trochanteric bursa injection, which deposits a combination local anesthetic and cortisone directly to the involved bursa. When performed by a physician who can accurately access the inflamed bursa, this procedure is usually very effective.
 

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 TENDINITIS

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.
 

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 tendinitis, although ultrasound may be used to confirm the diagnosis. The diagnosis is typically made based on the athlete's history
 

Treatment
    Initial treatment includes anti-inflammatory medication and avoidance of the offend­ing repetitive motions. Ice may provide some relief, especially for very thin athletes as this tendon lies quite deep within the 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.
 

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 a progressive, insidious development of pain. Pain is noted in the medial thigh or groin and is worse with adduction (pulling 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, osteitis pubis, hernia, and hip joint osteoarthritis should all be ruled out as possible sources of the groin pain. X-rays can rule out avulsion fractures and osteitis pubis. MRI can evaluate the possibility of other conditions and also localize and quantify the extent of muscle and other soft tissue injury.
 

Treatment
    Treatment for adductor strains is similar to that for other muscle strains. The treatment starts with PRICE 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 isokinetic testing of the injured leg is within 10 percent of the uninjured leg 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 LATERAL TEAR

Common Causes
    The hip labrum is a cartilagenous extension of the bony acetabulum, adding depth and stability to the hip joint. Both nociceptive (pain) and propioceptive (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 when thrusting the hip forward, pivoting, or kicking. Suspect posterior labral tears when similar symptoms are elicited by pushing posteriorly through a flexed femur as when thrusting the hip backward. Active range of motion of the hip might produce a snapping sensation, which could be a result of a tight iliotibial band laterally or a hypermobile iliopsoas tendon anteromedially. Generally, if the hip is truly passively ranged (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 intra articular 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), which can stress the labrum and predispose an athlete to labral tears, osteitis pubis, or osteoarthritis, which might mimic or accompany labral injuries. Magnetic resonance arthrogram, enhanced by a diluted contrast solution injected into the hip beforehand, has been shown to improve sensitivity of detection of labral tears over conventional MR!. 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). Compres­sion of the artery occurs when an abnormal musculotendinous band arises from the adductor muscle mass. This might be either congenital or acquired as a result of training or an injury such as a kick to the inner thigh in soccer. This syndrome is very rare but is more common in young and athletic people than in other populations.
 

Identification
    Athletes with this syndrome report worsening lower leg claudication (leg pain or fatigue from poor circulation), which is exacerbated by activity and relieve<i by rest. During physical exam, pulses are diminished or absent in the involved extremity. 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. Following surgery, a rehab program is 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 post surgery and is overseen by the surgeon and a physical therapist.

PELVIC STRESS FRACTURE

Common Causes
    Because of the design and strength of the pelvis, it takes a great deal of force for a fracture to occur. Adolescents and amenorrheic women are most vulnerable to bony pathology of the pelvis. Stress fractures of the pelvis usually occur in the pubic rami (a group of four bones in the front of the pelvis) and are associated with long-dis­tance running. Anorexic and amenorrheic female athletes are most vulnerable to pelvic stress fractures. The cause of injury is believed to be the repetitive pounding of forces transferred through the legs to the pelvis, making long-distance runners particularly susceptible.
 

Identification
    Many stress fractures go undetected when athletes opt not to seek treatment for nonspecific pain. Most conditions 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 increase in training activity. X-ray can detect stress fractures occasionally, but bone scan or MRI is more reliable. Stress fractures are most likely localized to the pubic rami but can occur elsewhere, including the neck of the femur.
 

Treatment
    Treatment includes rest, analgesics as needed, and addressing the underlying cause of the injury. Nutritional and hormonal deficiencies should be corrected. If stress fractures recur, a thorough metabolic work-up is necessary. In females, bone density studies are recommended to check for underlying osteoporosis. Female athletes with stress fractures should be screened for the female athlete triad as an underlying cause; the triad includes amenorrhea, osteopenia or osteoporosis, and poor diet or disordered eating. If the triad is suspected, the athlete should be referred for counseling.
 

Return to Action
    Athletes can usually return to action in four to six weeks. 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.

PELVIS AVULSION FRACTURES

Common Causes
    An avulsion is a tearing away. Avulsion fractures of the pelvis are seen primarily in adolescents and occur in three locations. Jumping sports such as basketball or vol­leyball can cause strong contraction of the sartorius muscle with an avulsion of the anterior superior iliac spine (the bump which can easily be felt over the front part of the hip region). Kicking sports such as American football or soccer with strong contraction of the rectus femoris can cause avulsion of the anterior inferior iliac spine (front part of the hip region just below the anterior superior iliac spine). Running sports may cause avulsion of the ischial tuberosity (the bone we sit on) with strong contraction of the hamstrings.
 

Identification
    Symptoms of avulsion fracture include sudden onset of pain localized 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.
 

Treatment
    Treatment of fractures to the front part of the hip 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. 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 one to two centimeters should undergo early surgical repair.
 

Return to Action
    Athletes may return to their sport once they have recovered strength in the associated muscles and there is callus formation in the fracture. Isokinetic testing can be used to accurately compare strength, and X-rays can assess maturing callus. Return time is generally six weeks to four months.

SNAPPING HIP FRACTURE

Common Causes
    A snapping hip can be caused by several pathologic processes that result in a characteristic snapping sensation when tendons in the hip region pop over bony prominences. Snapping I hip occurs in runners, triathletes, cheerleaders, dancers, and occasionally recreational athletes. The snapping usually results from the iliotibial band (the muscle along the outer part of the thigh) moving over the greater trochanter (the bump on the outer side of the hip). Other causes include acetabular labrum tears within the hip joint, iliopsoas tendon snapping over the pectineal eminence, and intraarticular loose bodies. With all these conditions, motion creates a "bow string" effect, causing an audible or palpable snap or click.
 

Identification

    Snapping from intra articular pathology will likely cause gait abnormalities and pain with weight bearing. If an athlete has significant pain or instability with hip range of motion, diagnostic imaging should be performed to rule out intra articular bone fragments or a tear of the acetabular labrum. Extraarticular snapping may be felt over the greater trochanter with passive ranging of the hip or while walking. A trainer can walk with the athlete with a hand over the greater trochanter to detect any snapping. Secondary trochanteric bursitis causes tenderness over the greater trochanter and pain when lying on the affected side. Examination involves rotation of the hip while held in an adducted position to feel the iliotibial band snapping over the greater trochanter. Extending the hip from a flexed position might provoke snapping of the iliopsoas tendon over the pectineal eminence.
 

Treatment
    Treatment for snapping hip focuses on stretching and strengthening of the hip abductors and adductors, hip flexors, and iliotibial band. The athlete should rest and avoid activities associated with the snapping. Anti-inflammatory medications might be required for pain or associated bursitis. Persisting problems might require cortisone shots into the bursa or region of snapping. Continued hip problems may require surgical repair.
 

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 three weeks. Failure to improve in that time frame warrants corticosteroid injection and a referral to physical therapy for a formalized stretching program.

HIP POINTER

Common Causes
    Hip pointers (also known as iliac crest pain) are contusions that occur along the pelvis, particularly the iliac crest's anterior and lat­eral hip area. This injury is generally caused by direct trauma to the iliac crest by another player (such as being struck by a helmet in American football, kicked by a foot in soccer, checked by a lacrosse stick, or 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, the injured athlete reports pain while performing a sit-up or with resisted trunk rotation or resisted hip abduction (moving the leg out laterally away from the midline). Swelling and bruising over the injury site usually indicates a more significant injury. Irritation to touch and severe bruising suggest an underlying fracture and warrant prompt referral to a physician for diagnostic evaluation. MRI best determines which structures are involved and to what degree, information that affects the design of a rehab program.
 

Treatment
    Initial treatment includes prompt application of ice, alternating 5 minutes on and 5 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, and 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. Treatment by an athletic trainer or physical therapist might then include electrical stimulation to contract the injured surrounding muscle to reduce edema and retard atrophy. At 7 to 10 days post injury, ultrasound may be added to promote deep warming of the injured tissues, making them more compliant to stretching and increasing blood flow to the region.
    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, refer the athlete to a rehab physician 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 a 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 attach and act on the pelvis, caus­ing instability. Osteitis pubis and ath­letic pubalgia can occur independently, or one condition can influence the development of the other. By definition athletic pubalgia is a painful condition, but the degenerative changes of the pubic bones of osteitis pubis mayor 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 non-
contact sports such as soccer, cross-country running and 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 or football, sprinting or cutting while running or during hockey or skating, and jumping in figure skating. Impaction of the pubic symphysis by a helmet or compression of the pubis by a forceful tackle or 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 while swinging a bat, or by a single forced extension (backward bending) of the trunk, such as when a running back is tackled full-on while changing direction (cutting) or when a quarterback has his 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 defenseman.
 

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 his or her legs, and the physician, trainer, or therapist attempts to push the legs apart) or when lying on their back they lift one leg up against resistance. All these maneuvers place strain on the injured pubic symphysis, causing pain.
    Athletes with athletic pubalgia typically have an acute, rather than gradual, onset discomfort in the mid- to lower-abdominal region initially and, if left untreated, might begin to experience pain in either or both medial thighs and inguinal (groin) regions. One theory suggests that tears of the abdominal rectus muscle tendon weaken and redistribute the balance of support 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 genitialia and anus. Performing resisted hip adduction, double-leg lifts, or resisted trunk rotation will replicate the pain. Only 25 percent or so 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 osteoarthritis, another cause of groin and medial thigh pain. MRI of the pelvis might reveal asym­metry or strain of the abdominal rectus muscles, inflammation or tear of the distal rectus abdominis tendon, 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 14 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 to these conditions, presumably by further stretching of the fasciae and muscle, resetting the stretch reflex, and reducing edema in the affected muscles. Therapeutic massage may be added about four weeks post injury. Should symptoms persist, a corticosteroid may be injected to the pubic symphysis in the case of osteitis pubis or to the proximal adductor tendon insertion on the lower portion of the pubic bone in the case of athletic pubalgia.
    Once symptoms have subsided, reconditioning exercises may begin. Stationary cycling, water walking or jogging, and walking on level ground should be initiated. 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. 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.
    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.
If athletes do not respond favorably to the treatment regimen described here 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 gender; 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 the degenerative changes of osteitis pubis result in such significant instability of the pubic symphysis that surgical fusion is required. In cases of athletic pubalgia resistant to conservative treatment measures, referral to a general surgeon experienced in this condition is warranted for possible surgical repair and reattachment of weakened abdominal and pelvic floor musculature. For persistent medial thigh pain, a release of the adductor fascia (firm connective tissue that sur­rounds the muscle) is also performed. Rarely do abdominal braces or pelvic straps prove helpful in either osteitis pubis or athletic pubalgia.
 

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.

COCCYXGEAL FRACTURE

Common Causes
    The coccyx, commonly called the tailbone, is comprised of four fused segments and is attached to the lowest portion of the sacrum by the sacrococcyxgealligament and to the pelvis by the sacrospinalligaments. 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 a fall onto a hard surface in the sitting position and landing squarely on one's buttocks or when struck by a swift-moving object such as a lacrosse ball, baseball, hockey puck, or shoe. A coccyxgeal 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 sacro­coccyxgealligament. Fractures might be initially missed by X-rays because the fracture segments might not be displaced. MRI 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 coccyxgeal 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 of 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, inflatable donut, or 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 an anesthetic and lidocaine. Manual therapies (via rectal exam) can be done to realign a malaligned coccyxgeal segment. This technique may be extremely helpful in reducing pain. Only in the most stubborn chronic conditions should the athlete refer 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 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 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 when 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 is 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 is 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 lowest segment of the spine (the sacrum) and forms a joint with each of the adja­cent iliac bones. 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 osteoarthritis, 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 acutely injured 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, rectal, or 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 (five minutes on and five minutes off) 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 X-ray guidance to reduce pain and inflammation. Rarely, in chronic cases of this condition in which joint laxity persists, the 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 he or she can do sport-specific activities without post exercise or delayed­onset 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 a pelvic nerve injury, such as an affliction to the ilioinguinal nerve or genitofemoral nerve. Athletes might become symptomatic some time after the traumatic event when scarring or fibrosis develop. Less common nerve entrapments causing hip pain involve the cluneal nerve and lateral femoral cutaneous nerve (LFCN).
 

Identification
    Symptoms of ilioinguinal nerve injury include burning pain over the lower abdomen that might radiate down the thigh and into the genitalia. Tenderness of the nerve as it passes medial to the anterior superior iliac spine might occur. Genitofemoral nerve injury can cause numbness or burning of the medial thigh or genitalia. Symptoms might be exacerbated by extension of the hip or thigh. Maintaining a flexed posture can alleviate these symptoms. Nerve blocks might be required for definitive diagnosis. Lateral femoral cutaneous injury can cause numbness or burning of the anterior lateral thigh.
 

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 LFCN injury can be alleviated with a cortisone injection to the nerve near the anterior superior iliac spine (ASIS). In rare cases, surgical release of the nerve from surrounding compressive tissues might be required.
 

Return to Action
    Athletes should expect recovery to take four to six weeks. If pain persists and surgical decompression was performed, the athlete may be sidelined for three months. Conservative and postoperative rehabilitation focuses on range-of-motion exercises and core strengthening.

FROM: SPORTS INJURIES GUIDEBOOK By Robert S. Gotliv, DO Editor--Chapter 10